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To The buy kamagra canada visit homepage Editor. The messenger RNA treatment BNT162b2 (Pfizer–BioNTech) has 95% efficacy against erectile dysfunction disease 2019 (erectile dysfunction treatment).1 Qatar launched a mass immunization buy kamagra canada campaign with this treatment on December 21, 2020. As of March 31, 2021, a total of 385,853 persons had received at least one treatment dose and 265,410 had completed buy kamagra canada the two doses. Vaccination scale-up occurred as Qatar was undergoing its second and third waves of severe acute respiratory syndrome erectile dysfunction 2 (erectile dysfunction) , which were triggered by expansion of the B.1.1.7 variant (starting in mid-January 2021) and the B.1.351 variant (starting in mid-February 2021). The B.1.1.7 wave peaked during the first week of March, and the rapid expansion of B.1.351 started in mid-March and continues buy kamagra canada to the present day.

Viral genome sequencing buy kamagra canada conducted from February 23 through March 18 indicated that 50.0% of cases of erectile dysfunction treatment in Qatar were caused by B.1.351 and 44.5% were caused by B.1.1.7. Nearly all cases in which kamagra was sequenced after March 7 were caused by either B.1.351 or B.1.1.7. Data on vaccinations, polymerase-chain-reaction testing, and buy kamagra canada clinical characteristics were extracted from the national, federated erectile dysfunction treatment databases that have captured all erectile dysfunction–related data since the start of the epidemic (Section S1 of the Supplementary Appendix, available with the full text of this letter at NEJM.org). treatment effectiveness was estimated with a test-negative case–control study design, a preferred design for assessing treatment effectiveness against influenza (see the Supplementary Appendix).2 A buy kamagra canada key strength of this design is the ability to control for bias that may result from differences in health care–seeking behavior between vaccinated and unvaccinated persons.2 Table 1. Table 1 buy kamagra canada.

treatment Effectiveness against and against Disease in Qatar. The estimated effectiveness of the treatment against any documented with the B.1.1.7 variant was 89.5% (95% confidence interval [CI], 85.9 to 92.3) at 14 or more days after buy kamagra canada the second dose (Table 1 and Table S2). The effectiveness against any documented buy kamagra canada with the B.1.351 variant was 75.0% (95% CI, 70.5 to 78.9). treatment effectiveness against severe, critical, or fatal disease due to with any erectile dysfunction (with the B.1.1.7 and B.1.351 variants being predominant within Qatar) was very high, at 97.4% (95% CI, 92.2 to 99.5). Sensitivity analyses buy kamagra canada confirmed these results (Table S3).

treatment effectiveness was also assessed with the use of a cohort study design by comparing the incidence of among vaccinated persons with the incidence in the national cohort of persons who were antibody-negative buy kamagra canada (Section S2). Effectiveness was estimated to be 87.0% (95% CI, 81.8 to 90.7) against the B.1.1.7 variant and 72.1% (95% CI, 66.4 to 76.8) against the B.1.351 variant, findings that confirm the results buy kamagra canada reported above. The BNT162b2 treatment was effective against and disease in the population of Qatar, despite the B.1.1.7 and B.1.351 variants being predominant within the country. However, treatment effectiveness against the B.1.351 variant buy kamagra canada was approximately 20 percentage points lower than the effectiveness (>90%) reported in the clinical trial1 and in real-world conditions in Israel4 and the United States.5 In Qatar, as of March 31, breakthrough s have been recorded in 6689 persons who had received one dose of the treatment and in 1616 persons who had received two doses. Seven deaths from erectile dysfunction treatment have been buy kamagra canada also recorded among vaccinated persons.

Five after the first dose and two after the second dose. Nevertheless, the reduced protection against with the B.1.351 variant did not buy kamagra canada seem to translate into poor protection against the most severe forms of (i.e., those resulting in hospitalization or death), which was robust, at greater than 90%. Laith J buy kamagra canada. Abu-Raddad, Ph.D.Hiam Chemaitelly, M.Sc.Weill Cornell Medicine–Qatar, Doha, Qatar [email protected]Adeel A. Butt, M.D.Hamad Medical Corporation, Doha, Qatarfor buy kamagra canada the National Study Group for erectile dysfunction treatment Vaccination Supported by the Biomedical Research Program and the Biostatistics, Epidemiology, and Biomathematics Research Core at Weill Cornell Medicine–Qatar.

The Ministry of Public buy kamagra canada Health. And Hamad buy kamagra canada Medical Corporation. The Qatar Genome Program supported the viral genome sequencing. Disclosure forms provided by the authors are available with the full buy kamagra canada text of this letter at NEJM.org. This letter was published on May 5, 2021, at buy kamagra canada NEJM.org.

Members of the National Study Group for erectile dysfunction treatment Vaccination are listed in the Supplementary Appendix, available with the full text of this letter at NEJM.org. 5 References1 buy kamagra canada. Polack FP, Thomas SJ, Kitchin N, buy kamagra canada et al. Safety and efficacy of the BNT162b2 mRNA erectile dysfunction treatment. N Engl J buy kamagra canada Med 2020;383:2603-2615.2.

Jackson ML, buy kamagra canada Nelson JC. The test-negative buy kamagra canada design for estimating influenza treatment effectiveness. treatment 2013;31:2165-2168.3. erectile dysfunction treatment clinical management buy kamagra canada. Living guidance buy kamagra canada.

Geneva. World Health Organization, January 25, buy kamagra canada 2021 (https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1).Google Scholar4. Dagan N, buy kamagra canada Barda N, Kepten E, et al. BNT162b2 mRNA erectile dysfunction treatment in a nationwide mass vaccination buy kamagra canada setting. N Engl J Med 2021;384:1412-1423.5.

Thompson MG, Burgess JL, Naleway buy kamagra canada AL, et al. Interim estimates of treatment effectiveness of BNT162b2 and mRNA-1273 erectile dysfunction treatments in preventing erectile dysfunction among health care personnel, first responders, and other essential and frontline workers — eight U.S buy kamagra canada. Locations, December 2020–March 2021. MMWR Morb Mortal Wkly Rep 2021;70:495-500.10.1056/NEJMc2104974-t1Table buy kamagra canada 1. treatment Effectiveness buy kamagra canada against and against Disease in Qatar.

Type of or DiseasePCR-Positive PersonsPCR-Negative PersonsEffectiveness (95% CI)*VaccinatedUnvaccinatedVaccinatedUnvaccinatednumber of personspercentPCR-confirmed with the buy kamagra canada B.1.1.7 variant†After one dose89218,075124117,72629.5 (22.9–35.5)≥14 days after second dose5016,35446515,93989.5 (85.9–92.3)PCR-confirmed with the B.1.351 variant‡After one dose132920,177158019,92616.9 (10.4–23.0)≥14 days after second dose17919,39669818,87775.0 (70.5–78.9)Disease§Severe, critical, or fatal disease caused by the B.1.1.7 variantAfter one dose304686143754.1 (26.1–71.9)≥14 days after second dose040120381100.0 (81.7–100.0)Severe, critical, or fatal disease caused by the B.1.351 variantAfter one dose45348353580.0 (0.0–19.0)≥14 days after second dose030014286100.0 (73.7–100.0)Severe, critical, or fatal disease caused by any erectile dysfunctionAfter one dose1391,9662201,88539.4 (24.0–51.8)≥14 days after second dose31,6921091,58697.4 (92.2–99.5)V-safe Surveillance. Local and Systemic Reactogenicity in Pregnant Persons Table 1. Table 1 buy kamagra canada. Characteristics of Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA buy kamagra canada erectile dysfunction treatment. Table 2.

Table 2 buy kamagra canada. Frequency of Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in buy kamagra canada Pregnant Persons. From December 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant. Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and buy kamagra canada those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively). Most participants (85.8% and 87.4%, respectively) reported being pregnant at the buy kamagra canada time of vaccination (Table 1).

Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for buy kamagra canada both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments. Figure 1 buy kamagra canada. Figure 1 buy kamagra canada. Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on the Day after mRNA erectile dysfunction treatment Vaccination.

Shown are solicited reactions in pregnant persons and nonpregnant women 16 to 54 years of age who received a messenger buy kamagra canada RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These buy kamagra canada patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency buy kamagra canada between pregnant persons and nonpregnant women were observed for specific reactions (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar. Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy buy kamagra canada Registry.

Pregnancy Outcomes and Neonatal buy kamagra canada Outcomes Table 3. Table 3. Characteristics of V-safe buy kamagra canada Pregnancy Registry Participants. As of March 30, 2021, the v-safe pregnancy registry call buy kamagra canada center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination. Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility).

The registry enrolled 3958 participants with vaccination from December 14, 2020, buy kamagra canada to February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a erectile dysfunction treatment diagnosis during pregnancy (97.6%) (Table buy kamagra canada 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) buy kamagra canada in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3). Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had buy kamagra canada been made at the time of this analysis.

Table 4 buy kamagra canada. Table 4. Pregnancy Loss and buy kamagra canada Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants. Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 buy kamagra canada (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester.

Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among buy kamagra canada those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal deaths were reported at the time buy kamagra canada of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception buy kamagra canada period, and no specific pattern of congenital anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed literature (Table 4). Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and buy kamagra canada processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons.

155 (70.1%) buy kamagra canada involved nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown buy kamagra canada or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Trial Design and Participants From August 17, 2020, through November 25, 2020, buy kamagra canada we enrolled participants at 16 sites in South Africa. The trial was designed to provide a buy kamagra canada preliminary evaluation of treatment safety and efficacy during ongoing kamagra transmission of erectile dysfunction.

Participants were healthy adults between the ages of 18 and 84 years without human immunodeficiency kamagra (HIV) or a subgroup of adults between the ages of 18 and 64 years with HIV whose condition was medically stable. Baseline IgG antibodies against the spike protein (anti-spike IgG antibodies) were buy kamagra canada measured at study entry to help determine baseline erectile dysfunction serostatus for the analysis of treatment efficacy. As a safety measure, enrollment was staggered into stage 1 (defined by the first third of targeted enrollment) buy kamagra canada and stage 2 (the remainder of enrollment) for both HIV-negative and HIV-positive participants. Progression from stage 1 to stage 2 in each group required a favorable review of safety data through day 7 from the previous stage against prespecified rules that would trigger a pause in treatment administration. (Details regarding the participants in each stage are provided in Table S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org.) Key exclusion criteria buy kamagra canada were pregnancy, long-term receipt of immunosuppressive therapy, autoimmune or immunodeficiency disease except for medically stable HIV , a history of confirmed or suspected erectile dysfunction treatment, and erectile dysfunction as confirmed on a nucleic acid amplification test (NAAT) performed as part of screening within 5 days before anticipated initial administration of the treatment or placebo.

All the participants buy kamagra canada provided written informed consent before enrollment. Additional details regarding the trial design, conduct, oversight, and analyses are provided in the Supplementary Appendix and the protocol (which includes the statistical analysis plan), available at NEJM.org. Oversight The NVX-CoV2373 treatment was developed by Novavax, which sponsored the trial and was responsible for the overall design (with input from the lead investigator), site buy kamagra canada selection, monitoring, and analysis. Trial investigators were responsible for data collection buy kamagra canada. The protocol was approved buy kamagra canada by the South African Health Products Regulatory Authority and by the institutional review board at each trial center.

Oversight of safety, which included monitoring for specific vaccination-pause rules, was performed by an independent safety monitoring committee. The first author wrote the first draft of buy kamagra canada the manuscript with assistance from a medical writer who is an author and an employee of Novavax. All the authors made the decision to submit the manuscript for publication and vouch buy kamagra canada for the accuracy and completeness of the data and for the fidelity of the trial to the protocol. Trial Procedures Participants were randomly assigned in a 1:1 ratio to receive two intramuscular injections, 21 days apart, of either NVX-CoV2373 (5 μg of recombinant spike protein with 50 μg of Matrix-M1 adjuvant) or saline placebo (injection volume, 0.5 ml), administered by staff members who were aware of trial-group assignments but were not otherwise involved with other trial procedures or data collection. All other staff members and trial participants remained buy kamagra canada unaware of trial-group assignments.

Participants were scheduled for in-person follow-up visits on days 7, 21, and 35 and at 3 months and 6 months to collect vital signs, review any adverse events, discuss changes in concomitant medications, and buy kamagra canada obtain blood samples for immunogenicity analyses. A follow-up telephone visit was scheduled buy kamagra canada for 12 months after vaccination. Safety Assessments The primary safety end points were the occurrence of all unsolicited adverse events, including those that were medically attended, serious, or of special interest, through day 35 (Tables S2 and S3) and solicited local and systemic adverse events that were evaluated by means of a reactogenicity diary for 7 days after each vaccination (Tables S4 and S5). Safety follow-up was ongoing through month 12 buy kamagra canada. Efficacy Assessments The primary efficacy end point was confirmed symptomatic erectile dysfunction treatment that was categorized as mild, buy kamagra canada moderate, or severe (hereafter called symptomatic erectile dysfunction treatment) and that occurred within 7 days after receipt of the second injection (i.e., after day 28) (Table S6).

Starting on day 8 and continuing through 12 months, we performed active surveillance (telephone calls every 2 weeks from trial sites to participants) and passive surveillance (telephone contact at any time from participants to trial sites) for symptoms of suspected erectile dysfunction treatment (Table S7 and Fig. S1). A new onset of suspected symptoms of erectile dysfunction treatment triggered initial in-person and follow-up surveillance visits to perform clinical assessments (vital signs, including pulse oximetry, and a lung examination) and for collection of nasal swabs (Fig. S2). In addition, suspected erectile dysfunction treatment symptoms were also assessed and nasal swabs collected at all scheduled trial visits.

Nasal-swab samples were tested for the presence of erectile dysfunction by NAAT with the use of the BD MAX system (Becton Dickinson). We used the InFLUenza Patient-Reported Outcome (FLU-PRO) questionnaire to comprehensively assess symptoms for the first 10 days of a suspected episode of erectile dysfunction treatment. Whole-Genome Sequencing In a blinded fashion, we performed post hoc whole-genome sequencing of nasal samples obtained from all the participants who had symptomatic erectile dysfunction treatment. Details regarding the whole-genome sequencing methods and phylogenetic analysis are provided in Fig. S3.

Statistical Analysis The safety analysis population included all the participants who had received at least one injection of NVX-CoV2373 or placebo. Regardless of group assignment, participants were evaluated according to the intervention they had actually received. Safety analyses were presented as numbers and percentages of participants who had solicited local and systemic adverse events through day 7 after each vaccination and who had unsolicited adverse events through day 35. We performed a per-protocol efficacy analysis in the population of participants who had been seronegative for erectile dysfunction at baseline and who had received both injections of NVX-CoV2373 or placebo as assigned, had no evidence of erectile dysfunction (by NAAT or anti-spike IgG analysis) within 7 days after the second injection (i.e., before day 28), and had no major protocol deviations affecting the primary efficacy outcome. A second per-protocol efficacy analysis population was defined in a similar fashion except that participants who were seropositive for erectile dysfunction at baseline could be included.

treatment efficacy (calculated as a percentage) was defined as (1–RR)×100, where RR is the relative risk of erectile dysfunction treatment illness in the treatment group as compared with the placebo group. The official, event-driven efficacy analysis targeted a minimum number of 23 end points (range, 23 to 50) to provide approximately 90% power to detect treatment efficacy of 80% on the basis of an incidence of symptomatic erectile dysfunction treatment of 2 to 6% in the placebo group. This analysis was performed at an overall one-sided type I error rate of 0.025 for the single primary efficacy end point. The relative risk and its confidence interval were estimated with the use of Poisson regression with robust error variance. Hypothesis testing of the primary efficacy end point was performed against the null hypothesis of treatment efficacy of 0%.

The success criterion required rejection of the null hypothesis to show a statistically significant treatment efficacy..

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The ethnic disparities kamagra usa include overall numbers of cases, as well as the relative numbers of critical care admissions and deaths.1In the area of mental health, for people from BAME groups, even before the current kamagra there were already significant mental health inequalities.2 These inequalities have been increased by the kamagra in several ways. The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general. This difficulty will increase pre-existing inequalities where there are challenges to kamagra usa engaging people in care and in providing early access to services.

The restrictions may also reduce the flexibility of care offers, given the need for social isolation, limiting non-essential travel and closure of routine clinics. The service impacts are kamagra usa compounded by constraints on the use of non-traditional or alternative routes to care and support.In addition, there is growing evidence of specific mental health consequences from significant erectile dysfunction treatment , with increased rates of not only post-traumatic stress disorder, anxiety and depression, but also specific neuropsychiatric symptoms.3 Given the higher risks of mental illnesses and complex care needs among ethnic minorities and also in deprived inner city areas, erectile dysfunction treatment seems to deliver a double blow. Physical and mental health vulnerabilities are inextricably linked, especially as a significant proportion of healthcare workers (including in mental health services) in the UK are from BAME groups.Focusing on mental health, there is very little erectile dysfunction treatment-specific guidance on the needs of patients in the BAME group.

The risk to staff in general healthcare (including mental healthcare) is a particular concern, and in response, the Royal College of Psychiatrists and NHS England have produced a report on the impact of erectile dysfunction treatment on BAME staff in mental healthcare settings, with guidance on assessment and management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician kamagra usa in balancing different risks for individual mental health patients and treating appropriately. Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the erectile dysfunction treatment kamagra. While syntheses of kamagra usa the existing guidelines are available about erectile dysfunction treatment and mental health,6 7 there is nothing specific about the healthcare needs of patients from ethnic minorities during the kamagra.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best evidence available.

Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, and personal relationships with patients and carers from ethnic minority backgrounds in kamagra usa order to continue existing care and to identify changes needed to respond to worsening of mental health.Consider modifications to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of erectile dysfunction treatment in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of erectile dysfunction treatment and mental health8 and also a clear need for specific research focusing on the post-erectile dysfunction treatment mental health needs kamagra usa of people from the BAME group.

Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe. Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a first step in this process.2 At this early stage, the guidance for assessing risks of erectile dysfunction treatment kamagra usa for health professionals is also useful for patients, until more refined decision support and prediction tools are developed. A recent Public Health England report on ethnic minorities and erectile dysfunction treatment9 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates.

Furthermore, the report kamagra usa recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and erectile dysfunction treatment , integrated care systems that work well for susceptible and marginalised groups, culturally competent health promotion, prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection will need to cover not only hospital admissions but also data from primary care, linking information on mental health, erectile dysfunction treatment and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender. Now we also need to focus on an equally important aspect of kamagra usa vulnerability.

As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

erectile dysfunction treatment has evolved rapidly into http://dangwrite.com/what-do-i-need-to-buy-zithromax/ a kamagra with global buy kamagra canada impacts. However, as the buy kamagra canada kamagra has developed, it has become increasingly evident that the risks of erectile dysfunction treatment, both in terms of rates and particularly of severe complications, are not equal across all members of society. While general risk factors for hospital admission with erectile dysfunction treatment include age, male sex and specific comorbidities (eg, cardiovascular disease, hypertension and diabetes), there is increasing evidence that people identifying with Black, Asian and Minority Ethnic (BAME) groupsi have disproportionately higher risks of being adversely affected by erectile dysfunction treatment in the UK and the USA. The ethnic disparities include overall numbers of cases, as well as the relative numbers of critical care admissions and deaths.1In the area of mental health, for people from BAME groups, even before the current kamagra there buy kamagra canada were already significant mental health inequalities.2 These inequalities have been increased by the kamagra in several ways.

The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general. This difficulty will increase pre-existing inequalities where there are challenges to engaging people in care buy kamagra canada and in providing early access to services. The restrictions may also reduce the flexibility of care offers, given the need for social isolation, limiting non-essential travel and closure of routine clinics. The service impacts are compounded by constraints on the use of non-traditional or alternative routes to care and support.In addition, there is growing evidence of specific mental health consequences from significant erectile dysfunction treatment , with increased rates of not only post-traumatic stress disorder, anxiety and depression, but buy kamagra canada also specific neuropsychiatric symptoms.3 Given the higher risks of mental illnesses and complex care needs among ethnic minorities and also in deprived inner city areas, erectile dysfunction treatment seems to deliver a double blow.

Physical and mental health vulnerabilities are inextricably linked, especially as a significant proportion of healthcare workers (including in mental health services) in the UK are from BAME groups.Focusing on mental health, there is very little erectile dysfunction treatment-specific guidance on the needs of patients in the BAME group. The risk to staff in general healthcare (including mental healthcare) is a particular concern, and in response, the Royal College of Psychiatrists and NHS England have produced a report on the impact of erectile dysfunction treatment on BAME staff in mental healthcare settings, with guidance on assessment and buy kamagra canada management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician in balancing different risks for individual mental health patients and treating appropriately. Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the erectile dysfunction treatment kamagra. While syntheses of the existing guidelines are buy kamagra canada available about erectile dysfunction treatment and mental health,6 7 there is nothing specific about the healthcare needs of patients from ethnic minorities during the kamagra.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best evidence available.

Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, and personal relationships with patients and carers from ethnic minority backgrounds in order to continue existing care and to identify changes needed to respond to worsening of mental buy kamagra canada health.Consider modifications to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of erectile dysfunction treatment in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of erectile dysfunction treatment and mental health8 and also a clear need for buy kamagra canada specific research focusing on the post-erectile dysfunction treatment mental health needs of people from the BAME group. Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe.

Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a first step in this process.2 At this early stage, the buy kamagra canada guidance for assessing risks of erectile dysfunction treatment for health professionals is also useful for patients, until more refined decision support and prediction tools are developed. A recent Public Health England report on ethnic minorities and erectile dysfunction treatment9 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates. Furthermore, the report recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and erectile dysfunction treatment , integrated care systems that work well for susceptible and marginalised groups, culturally competent health promotion, prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection will need to cover not only hospital buy kamagra canada admissions but also data from primary care, linking information on mental health, erectile dysfunction treatment and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender.

Now we buy kamagra canada also need to focus on an equally important aspect of vulnerability. As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

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Do not take Kamagra with any of the following:

  • cisapride
  • methscopolamine nitrate
  • nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
  • nitroprusside
  • other sildenafil products (Caverta, Silagra, Eriacta, etc.)

Kamagra 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.

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The past week has seen an explosion of media commentary about whether children in the UK http://electronickitssite.com/electronic-kits-the-tips-and-tricks-to-building-great-kits/ should ajanta pharma kamagra uk go back to school. Since ‘lockdown’ (23 March 2020) began schools have been ajanta pharma kamagra uk open to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools.

Viner et al1 produced a rapid systematic review that concludes that school closures have less impact on rate and mortality than other social ajanta pharma kamagra uk distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the UK on 10 May by the UK ajanta pharma kamagra uk prime minister, Boris Johnson.

He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from ajanta pharma kamagra uk 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools.

In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part ajanta pharma kamagra uk of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know ajanta pharma kamagra uk that there are children out there that have not spoken or played with another child their own age for the last two months.

They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest ajanta pharma kamagra uk children will be the ones who fall further behind if we keep school gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news ajanta pharma kamagra uk articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement.

The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has ajanta pharma kamagra uk caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit.

Is that ajanta pharma kamagra uk correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’. This provoked a great deal ajanta pharma kamagra uk of disquiet.

Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children of developing erectile dysfunction ajanta pharma kamagra uk disease. The second is the risk to others of children transmitting erectile dysfunction disease, either while being symptomatic or asymptomatic.

Here are some ajanta pharma kamagra uk of the available evidence.Morbidity and mortality in children from erectile dysfunction diseaseChildren appear to be less likely to acquire erectile dysfunction disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% of confirmed ajanta pharma kamagra uk cases (7.2% of admitted children).

Death was ajanta pharma kamagra uk reported in 15 cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the kamagra, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the kamagra.15There are concerns that children who have been infected with the kamagra can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for erectile dysfunction treatment, and in the absence of effective community testing it will be impossible to know if they are carrying the kamagra. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to ajanta pharma kamagra uk determine without much more extensive testing if a child can transmit the .Arav et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution.

They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential ajanta pharma kamagra uk gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of erectile dysfunction treatment has fallen below specified threshold.

This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would ajanta pharma kamagra uk not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools ajanta pharma kamagra uk are taken on a national level with a distance from personal concerns and fears.

Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is ajanta pharma kamagra uk a difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation.

Parents were being asked to believe that MMR was a safe treatment in the face of a massive and emotive campaign ajanta pharma kamagra uk that promoted the ‘risk’ of having the treatment above all else. This situation ajanta pharma kamagra uk is even more complex than that as we have increased access to opinion and difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult.

It is likely that evidence will continue to emerge and gradually the choice will become easier to make ajanta pharma kamagra uk. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a ajanta pharma kamagra uk consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are challenges to this approach.

For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to ajanta pharma kamagra uk consider objectively the views of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the ajanta pharma kamagra uk experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching ajanta pharma kamagra uk approach is based on a series of ‘rounds’, where a set of experts are asked their opinions on a particular issue.

The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings of each round are ajanta pharma kamagra uk always shared with the broader group anonymously. This avoids any bias ajanta pharma kamagra uk that might result from participants being concerned about their own views being viewed negatively or from their own opinions being biased by personal factors.

This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a ajanta pharma kamagra uk study of human factors that contributed to nursing errors used only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could.

Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them ajanta pharma kamagra uk to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round ajanta pharma kamagra uk 1, draft competencies were developed from the findings of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed ajanta pharma kamagra uk their consensus with the final document. The final document includes four competencies, each with several elements.

Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views of experts ajanta pharma kamagra uk on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time consuming ajanta pharma kamagra uk.

The need for participants to complete multiple rounds can lead to high drop-out rates which impacts on validity ajanta pharma kamagra uk of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those taking part with the opportunity to reflect and reconsider their position in response to additional information, which is an important part of nursing ajanta pharma kamagra uk practice.

Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity present in Delphi studies, ajanta pharma kamagra uk it is still unlikely that a group of experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it ajanta pharma kamagra uk has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the quality of evidence, with expert opinion viewed as providing a poor basis for making ajanta pharma kamagra uk judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among participants, ajanta pharma kamagra uk who are able to nuance and reconsider their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies.

It is important to try and prevent participants from simply resorting to agreeing ajanta pharma kamagra uk with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

The past week has seen an explosion of media commentary about whether buy kamagra canada children in the UK cheap kamagra tablets should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open buy kamagra canada to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools.

Viner et al1 produced a rapid systematic buy kamagra canada review that concludes that school closures have less impact on rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed buy kamagra canada to the population of the UK on 10 May by the UK prime minister, Boris Johnson.

He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various buy kamagra canada groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools.

In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety and buy kamagra canada welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that buy kamagra canada have not spoken or played with another child their own age for the last two months.

They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further buy kamagra canada behind if we keep school gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets buy kamagra canada and news articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement.

The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds buy kamagra canada are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit.

Is that correct? buy kamagra canada. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’. This provoked buy kamagra canada a great deal of disquiet.

Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children of developing erectile dysfunction disease buy kamagra canada. The second is the risk to others of children transmitting erectile dysfunction disease, either while being symptomatic or asymptomatic.

Here are some of the available evidence.Morbidity and mortality in children from buy kamagra canada erectile dysfunction diseaseChildren appear to be less likely to acquire erectile dysfunction disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% of confirmed cases (7.2% of admitted children) buy kamagra canada.

Death was buy kamagra canada reported in 15 cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the kamagra, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the kamagra.15There are concerns that children who have been infected with the kamagra can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for erectile dysfunction treatment, and in the absence of effective community testing it will be impossible to know if they are carrying the kamagra. Children also can buy kamagra canada have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the .Arav et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution.

They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a buy kamagra canada case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of erectile dysfunction treatment has fallen below specified threshold.

This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would buy kamagra canada not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken on a national level with a distance buy kamagra canada from personal concerns and fears.

Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is a difficult path buy kamagra canada to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation.

Parents were being asked to believe that MMR was a safe treatment in the face of a massive and emotive campaign that promoted the ‘risk’ of buy kamagra canada having the treatment above all else. This situation is even more complex http://metallicwebsites.net/?post_type=wpcf7_contact_form&p=4 than that as we have increased access to opinion and buy kamagra canada difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult.

It is likely that evidence will continue to emerge and gradually the buy kamagra canada choice will become easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are challenges to this buy kamagra canada approach.

For example, what should be done when consensus cannot be reached?. How can buy kamagra canada experts be engaged in a way that allows them to consider objectively the views of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the buy kamagra canada gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching approach buy kamagra canada is based on a series of ‘rounds’, where a set of experts are asked their opinions on a particular issue.

The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings of each round are always shared with the buy kamagra canada broader group anonymously. This avoids any bias that might result from participants being buy kamagra canada concerned about their own views being viewed negatively or from their own opinions being biased by personal factors.

This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study of human factors that contributed to nursing errors used only two buy kamagra canada rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could.

Analysis of buy kamagra canada responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the findings buy kamagra canada of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were buy kamagra canada made based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements.

Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible buy kamagra canada approach to gathering the views of experts on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time buy kamagra canada consuming.

The need for participants to complete multiple rounds can lead to high drop-out rates which impacts buy kamagra canada on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides buy kamagra canada those taking part with the opportunity to reflect and reconsider their position in response to additional information, which is an important part of nursing practice.

Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity buy kamagra canada present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it has been identified that buy kamagra canada in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to buy kamagra canada the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows buy kamagra canada for reflection among participants, who are able to nuance and reconsider their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies.

It is important to try and prevent participants from simply resorting to buy kamagra canada agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

Hoe lang werkt kamagra

How to cite this article:Singh OP hoe lang werkt kamagra. Mental health in diverse India. Need for advocacy hoe lang werkt kamagra. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in hoe lang werkt kamagra terms of geography – From the Himalayas to the deserts to the seas.

Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic hoe lang werkt kamagra development indexes. There is now ample evidence that sociocultural factors influence mental health. Compton and hoe lang werkt kamagra Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment.

This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low hoe lang werkt kamagra access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India. The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the hoe lang werkt kamagra less developed northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were hoe lang werkt kamagra found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a negative prognostic indicator contrary to the hoe lang werkt kamagra western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

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

Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and hoe lang werkt kamagra pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual level. There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global hoe lang werkt kamagra Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed hoe lang werkt kamagra a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with hoe lang werkt kamagra editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation.

When the enemy is economic inequality, our weapon hoe lang werkt kamagra is research highlighting the role of these factors on mental health. References 1.Compton MT, Shim RS. The social determinants hoe lang werkt kamagra of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health hoe lang werkt kamagra Survey of India, 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India. The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61.

4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India. 2019. Available from. Https://ncrb.gov.in.

[Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

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

Dhat syndrome (DS), the term coined by Dr. N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments.

Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients. The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

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

Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr.

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

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

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

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?. There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders.

Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness.

Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

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

This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS.

That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome. The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

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

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

38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety.

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

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%). Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure.

Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction.

The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders.

Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety.

The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis. Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years). The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill.

It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%).

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

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment. The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class.

Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%).

About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine.

In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years.

The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years. Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

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

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training. Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%).

Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality.

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

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different. While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification.

However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality.

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

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

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Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre. J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome.

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

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

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

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

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

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

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

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

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Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_791_20.

How to cite buy kamagra canada this article:Singh OP http://marthamukaiwa.com/buy-levitra-orodispersible-uk/. Mental health in diverse India. Need for buy kamagra canada advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in terms of geography – From the Himalayas buy kamagra canada to the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health buy kamagra canada infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

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

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and buy kamagra canada anxiety, the less developed northern states had more of childhood onset disorders.

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

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

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

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

There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden buy kamagra canada of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental buy kamagra canada Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

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

References 1.Compton MT, Shim RS. The social determinants of mental buy kamagra canada health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-16 buy kamagra canada. Prevalence, Patterns and Outcomes.

Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

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

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

Accidental Deaths and Suicides in India. 2019. Available from.

Https://ncrb.gov.in. [Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN.

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

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr.

N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding.

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

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome.

A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr. President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020.

I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

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

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

Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K. Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals.

I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions.

Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area. Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome.

A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology. Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS.

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

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue.

Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument.

However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter.

On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent.

The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder.

Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being.

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

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

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%).

The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness. Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic.

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

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

Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months.

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

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI).

Men with DS reported greater symptoms on BSI than those without DS. 60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI.

The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

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

It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban).

One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%).

In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice.

The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively.

The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression.

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

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

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic.

Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age.

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

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

Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse.

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

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains.

The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation. Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas.

In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

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

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

The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes.

Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single.

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

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

Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years.

The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS.

The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

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

Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata.

The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset. Only a few patients received higher education.

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

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management.

A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone.

Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual.

Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same. Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary.

CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

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

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial.

Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[PUBMED] [Full text] 47.Bhatia MS, Malik SC. Dhat syndrome – A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5.

48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?. J Ment Health Hum Behav1997;2:17-22.

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

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

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

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

52.Carstairs GM. The Twice Born. Bloomington.

Indiana University Press. 1961. 53.Carstairs GM.

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

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

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

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

Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. Current nosology of Dhat syndrome and state of evidence.

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

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

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

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

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

Adv Psychosom Med 2013;33:15-30. 62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11.

Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

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November 15, kamagra oral jelly canadian pharmacy 2021Largest US pork processor agrees to develop, implement infectious disease preparedness plan, health training for workersOSHA, Smithfield Packaged Meats Corp. Sign settlement agreement SIOUX FALLS, SD – Smithfield Packaged Meats Corp. €“ the country’s largest pork processor – has agreed to kamagra oral jelly canadian pharmacy assemble a team of company and third-party experts to develop an infectious disease preparedness plan that the company will implement at all of its processing facilities nationwide. In a settlement agreement with the U.S.

Department of Labor, Smithfield Packaged Meats kamagra oral jelly canadian pharmacy Corp. Has committed to changing its health procedures and training relating to infectious diseases. The action follows a March 2020 Occupational Safety and Health Administration inspection that led OSHA to cite the company under the general kamagra oral jelly canadian pharmacy duty clause for failing to protect workers from erectile dysfunction hazards at its Sioux Falls facility. As part of the agreement, Smithfield will pay the assessed penalty of $13,494.

In spring 2020, the company closed its Sioux Falls plant for 25 days in an effort to contain a erectile dysfunction treatment outbreak. By June 16, 2020, 1,294 Smithfield workers had tested kamagra oral jelly canadian pharmacy positive for erectile dysfunction treatment and four died. €œThe terms of this settlement are intended to ensure that Smithfield employees receive the training and protective measures necessary to protect them from exposure to the infectious diseases at their facilities,” said OSHA’s Regional Administrator Jennifer Rous in Denver. €œWhat happened at this facility was tragic and we must ensure that all steps in the agreement are followed to prevent a mass outbreak from happening again.” Under the terms of the agreement, Smithfield will continue to use its current erectile dysfunction treatment Preparedness and Response Plan to reduce employees’ exposure to the erectile dysfunction while working with third-party experts to assess plants’ operating procedures and develop the infectious kamagra oral jelly canadian pharmacy disease preparedness plan.

Smithfield must evaluate work areas and other areas where employees congregate to minimize employees’ potential exposure to infectious diseases. The team kamagra oral jelly canadian pharmacy of third-party experts and company representatives will also. Review Smithfield’s existing programs and procedures. Evaluate plant administrative and engineering kamagra oral jelly canadian pharmacy controls.

Identify personal protective equipment and respiratory protection needs. Address medical management functions through the facility’s onsite clinic, and identify issues associated with continuity of operations. Train and implement program requirements in languages and kamagra oral jelly canadian pharmacy at literacy levels that the workforce understands. Any written materials provided must also be in languages employees understand.

Following development of its infectious kamagra oral jelly canadian pharmacy disease preparedness plan, Smithfield agreed to review the plan and revise it as necessary to address potential new infectious diseases and guidance from federal, state and local public health authorities, as well as review annual union feedback on the plan and its procedures. Learn more about OSHA and the agency’s resources on erectile dysfunction protection. # # # Media Contacts kamagra oral jelly canadian pharmacy. Scott Allen, 312-353-4727, allen.scott@dol.govRhonda Burke, 312-353-4807, burke.rhonda@dol.govRelease Number.

21-1862-NAT U.S. Department of Labor news materials are accessible at http://www.dol.gov kamagra oral jelly canadian pharmacy. The department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).November 12, 2021Sunpro Solar’s owner cited again for exposing workers kamagra oral jelly canadian pharmacy to fall hazards after investigation at Naples work site.

Faces $160K in penaltiesMarc Jones Construction LLC put workers at risk in Texas in 2021, 2020 NAPLES, FL – Despite being cited twice in two years for exposing workers to dangerous fall hazards, one of the nation’s leading residential solar panel installation contractors has again violated federal workplace safety requirements, this time at a Naples work site. After an investigation by kamagra oral jelly canadian pharmacy the U.S. Department of Labor’s Occupational Safety and Health Administration, the agency cited Marc Jones Construction LLC – operating as Sunpro Solar – for a repeat violation after inspectors found workers exposed to falls, the leading cause of death and serious injuries in the construction industry. In addition, the agency cited the company for allowing workers to climb up and down extension ladders while carrying loads that could have caused them to fall, and failing to provide kamagra oral jelly canadian pharmacy fall protection training to employees.

OSHA cited the Louisiana-based company for similar violations twice in Texas, in San Antonio in January 2021 and in El Paso in April 2020. OSHA proposed $160,913 in penalties for the violations. €œMarc Jones Construction has ignored the law repeatedly and failed to protect their workers from well-known fall hazards,” said OSHA Area Director Condell Eastmond in kamagra oral jelly canadian pharmacy Fort Lauderdale, Florida. €œOSHA will continue holding this company accountable until they start meeting their obligations and complying with OSHA standards.” Based in Mandeville, Louisiana, Marc Jones Construction LLC is a commercial and residential solar panel installation company operating in 21 states.

In 2008, the company founded Sunpro Solar, ranked second on “Solar Power World” magazine’s 2021 list of top residential solar installers kamagra oral jelly canadian pharmacy in the U.S. The company has 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA’s area director, or contest the findings before the independent Occupational Safety and Health Review Commission. OSHA provides useful information on protecting roofing workers and the required use of fall protection in construction kamagra oral jelly canadian pharmacy. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees.

OSHA’s role is to ensure these conditions for kamagra oral jelly canadian pharmacy America’s workers by setting and enforcing standards, and providing training, education and assistance. Learn more about OSHA. # # # Media Contacts. Eric R kamagra oral jelly canadian pharmacy.

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The department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay)..

November 15, 2021Largest US pork processor agrees to https://www.peak-inspiration.com/news/ develop, implement infectious disease preparedness plan, buy kamagra canada health training for workersOSHA, Smithfield Packaged Meats Corp. Sign settlement agreement SIOUX FALLS, SD – Smithfield Packaged Meats Corp. €“ the country’s largest pork processor – has agreed to assemble a team of company and third-party experts to develop an infectious disease preparedness plan that the company will implement at buy kamagra canada all of its processing facilities nationwide. In a settlement agreement with the U.S.

Department of Labor, Smithfield Packaged Meats Corp buy kamagra canada. Has committed to changing its health procedures and training relating to infectious diseases. The action follows a March 2020 Occupational Safety and Health Administration inspection that led OSHA to cite the company under the general duty clause for failing to protect workers from erectile dysfunction hazards at its Sioux buy kamagra canada Falls facility. As part of the agreement, Smithfield will pay the assessed penalty of $13,494.

In spring 2020, the company closed its Sioux Falls plant for 25 days in an effort to contain a erectile dysfunction treatment outbreak. By June buy kamagra canada 16, 2020, 1,294 Smithfield workers had tested positive for erectile dysfunction treatment and four died. €œThe terms of this settlement are intended to ensure that Smithfield employees receive the training and protective measures necessary to protect them from exposure to the infectious diseases at their facilities,” said OSHA’s Regional Administrator Jennifer Rous in Denver. €œWhat happened at this facility was tragic and we buy kamagra canada must ensure that all steps in the agreement are followed to prevent a mass outbreak from happening again.” Under the terms of the agreement, Smithfield will continue to use its current erectile dysfunction treatment Preparedness and Response Plan to reduce employees’ exposure to the erectile dysfunction while working with third-party experts to assess plants’ operating procedures and develop the infectious disease preparedness plan.

Smithfield must evaluate work areas and other areas where employees congregate to minimize employees’ potential exposure to infectious diseases. The team buy kamagra canada of third-party experts and company representatives will also. Review Smithfield’s existing programs and procedures. Evaluate plant administrative and engineering controls buy kamagra canada.

Identify personal protective equipment and respiratory protection needs. Address medical management functions through the facility’s onsite clinic, and identify issues associated with continuity of operations. Train and implement program requirements in languages and at literacy buy kamagra canada levels that the workforce understands. Any written materials provided must also be in languages employees understand.

Following development of its buy kamagra canada infectious disease preparedness plan, Smithfield agreed to review the plan and revise it as necessary to address potential new infectious diseases and guidance from federal, state and local public health authorities, as well as review annual union feedback on the plan and its procedures. Learn more about OSHA and the agency’s resources on erectile dysfunction protection. # # buy kamagra canada # Media Contacts. Scott Allen, 312-353-4727, allen.scott@dol.govRhonda Burke, 312-353-4807, burke.rhonda@dol.govRelease Number.

21-1862-NAT U.S. Department of Labor news http://simniok-coaching.de/educationwp/ materials buy kamagra canada are accessible at http://www.dol.gov. The department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).November 12, 2021Sunpro Solar’s owner cited again for exposing workers to fall hazards after investigation at buy kamagra canada Naples work site.

Faces $160K in penaltiesMarc Jones Construction LLC put workers at risk in Texas in 2021, 2020 NAPLES, FL – Despite being cited twice in two years for exposing workers to dangerous fall hazards, one of the nation’s leading residential solar panel installation contractors has again violated federal workplace safety requirements, this time at a Naples work site. After an investigation by buy kamagra canada the U.S. Department of Labor’s Occupational Safety and Health Administration, the agency cited Marc Jones Construction LLC – operating as Sunpro Solar – for a repeat violation after inspectors found workers exposed to falls, the leading cause of death and serious injuries in the construction industry. In addition, the agency cited the company for allowing workers to buy kamagra canada climb up and down extension ladders while carrying loads that could have caused them to fall, and failing to provide fall protection training to employees.

OSHA cited the Louisiana-based company for similar violations twice in Texas, in San Antonio in January 2021 and in El Paso in April 2020. OSHA proposed $160,913 in penalties for the violations. €œMarc Jones Construction has ignored the law repeatedly and failed to protect their workers from buy kamagra canada well-known fall hazards,” said OSHA Area Director Condell Eastmond in Fort Lauderdale, Florida. €œOSHA will continue holding this company accountable until they start meeting their obligations and complying with OSHA standards.” Based in Mandeville, Louisiana, Marc Jones Construction LLC is a commercial and residential solar panel installation company operating in 21 states.

In 2008, the buy kamagra canada company founded Sunpro Solar, ranked second on “Solar Power World” magazine’s 2021 list of top residential solar installers in the U.S. The company has 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA’s area director, or contest the findings before the independent Occupational Safety and Health Review Commission. OSHA provides useful information on protecting roofing workers and the required use of fall buy kamagra canada protection in construction. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees.

OSHA’s role is to ensure these conditions for America’s workers buy kamagra canada by setting and enforcing standards, and providing training, education and assistance. Learn more about OSHA. # # # Media Contacts. Eric R buy kamagra canada.

Lucero, 678-237-0630, lucero.eric.r@dol.govErika B. Ruthman, 678-237-0630, buy kamagra canada ruthman.erika.b@dol.gov Release Number. 21-1977-ATL (300) U.S. Department of buy kamagra canada Labor news materials are accessible at http://www.dol.gov.

The department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay)..

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HARTFORD, CT buy kamagra 100mg – A Danbury bakery and its owner how can i get kamagra may not threaten, terminate or cause harm to current or former workers who cooperate with a U.S. Department of Labor investigation of the bakery’s employment practices, a federal court in Hartford has ordered in a consent preliminary injunction obtained by the department.The department’s Wage and Hour Division investigated Padaminas NY Bakery II LLC and owner Pedro Coelho for potential Fair Labor Standards Act violations. Shortly after the investigation began, the department alleged that Coelho buy kamagra 100mg met with his employees on two occasions. The department’s complaint states that during those meetings, Coelho told his employees he would fire them and report them to immigration authorities if they cooperated with the investigation.

The complaint also alleges that defendants blacklisted a former employee they believed filed buy kamagra 100mg a complaint with the division. The U.S. District Court for the District of Connecticut in Hartford issued a consent order prohibiting the bakery and its owner from retaliating against current and former employees and obstructing the division’s investigation. Due to the potential for ongoing retaliation by the defendants, the department buy kamagra 100mg sought and obtained the consent preliminary injunction.

The injunction prohibits the defendants from taking any of the following actions in violation of the FLSA. Terminating or threatening to terminate any employee buy kamagra 100mg. Reporting or threatening to report any employee or former employee to immigration authorities. Threatening to have any employee or former employee deported.

Using against buy kamagra 100mg any employee or former employee their immigration status, citizenship, work authorization status or lack of government documents (including a driver’s license). Disparaging or threatening to disparage any employee or former employee to other employers. Blacklisting any buy kamagra 100mg employee or former employee. Making any employees’ working conditions less favorable, including by reducing any employee’s hours of work or pay.

Retaliating or discriminating against employees or former employees in any other way. Obstructing buy kamagra 100mg the division’s investigation of the defendants. The consent injunction also requires the defendants to permit a division representative to notify all the defendants’ employees on paid working time of their FLSA rights, which includes their right to speak freely and honestly with the Wage and Hour Division without fear of retaliation, and provide a written notice of FLSA rights to all employees in a language they understand. €œThe Fair Labor Standards Act not only guarantees that employees receive all the wages they are due for the hours they work, it also forbids employers from retaliating against, punishing or blacklisting employees because they exercise their buy kamagra 100mg rights under the law,” said Wage and Hour Division District Director Donald Epifano in Hartford, Connecticut.

€œKnowing and understanding the law can prevent violations from occurring in the first place. We encourage employers and employees with questions buy kamagra 100mg about their respective responsibilities and rights to contact the Wage and Hour Division.” “The defendants’ alleged behavior is unlawful and extreme. Seeking to intimidate employees will not halt a Wage and Hour Division investigation. The U.S.

Department of Labor will, as in this case, respond buy kamagra 100mg with appropriate and expeditious legal action to protect employees’ rights and hold employers accountable for their retaliatory and obstructionist actions,” said regional Solicitor of Labor Maia Fisher in Boston. The division’s Hartford District Office best place to buy kamagra online is conducting the investigation. The department’s regional Office buy kamagra 100mg of the Solicitor is litigating the case. Workers can call the Wage and Hour Division confidentially with questions – regardless of their immigration status – and the department can speak with callers in more than 200 languages.

For more information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243). Learn more about the Wage and Hour Division, including a search tool to use if you think you may be buy kamagra 100mg owed back wages collected by the division. Walsh v. Padaminas NY buy kamagra 100mg Bakery II LLC and owner Pedro Coelho Civil Action No.

3:21-cv-1051WASHINGTON, DC – On Aug. 18, workers at the General Motors’ Silao plant in Mexico voted to reject a proposed collective bargaining buy kamagra 100mg agreement, an action heralded as a win for the labor protections built into the United States-Mexico-Canada Agreement.The vote comes as a result of a first-of-its-kind comprehensive plan to remediate a past denial of freedom of association and collective bargaining rights for the workers at the plant, when irregularities were identified in an April 2021 collective bargaining legitimization vote. A result of the first self-initiated petition under USMCA’s Rapid Response Mechanism, the plan laid out steps to ensure workers at the facility were able to participate in a vote on their collective bargaining agreement free of interference. Mexican labor inspectors and observers from the International Labor Organization were at GM’s facilities in Silao two weeks prior to the vote and during the vote itself to ensure a fair process.

The Rapid Response Mechanism under the USMCA allows buy kamagra 100mg the U.S. To take expedited enforcement actions based on the actions of individual factories in Mexico that fail to comply with domestic freedom of association and collective bargaining laws. €œSecretary of Labor Marty Walsh buy kamagra 100mg fought hard for this result. Now, thanks to the U.S.-Mexico-Canada Agreement labor protections, the workers at the General Motors’ Silao plant are able to exercise their voice in determining the future of their collective bargaining agreement,” said Deputy Undersecretary for International Affairs Thea Lee.

€œThis is an example of successful collaboration between the department, the Office of the U.S. Trade Representative, buy kamagra 100mg and the government of Mexico. The U.S. Government remains committed to working with the Mexican government to make sure our trade policies work for workers.” Nearly 6,000 workers voted during a period of 34 hours, and 2,623 voted yes for the collective bargaining agreement while 3,214 buy kamagra 100mg voted no.

The “no" vote winning the majority of support means the current collective bargaining agreement will be nullified, and there will likely be a process set into motion for workers to choose the union they would like to represent them. The Mexican labor inspectorate now has 20 working days to review and certify results. The second phase of Mexico’s historic buy kamagra 100mg labor reform starts on Oct. 1 in 13 states, including Guanajuato, which contains GM’s Silao facility.

Unions in buy kamagra 100mg Mexico need to legitimize all collective bargaining agreements by May 2023. Given the enormity of this task and importance to advancing union democracy, the GM Silao process serves as a good case study and provides critical information for Mexico to strengthen policies like the collective bargaining agreement legitimation protocol that are key to elevating worker voices. Learn more about the department’s International Labor Affairs Bureau..

HARTFORD, CT – low cost kamagra A Danbury bakery and its owner may not threaten, terminate or cause harm to current or former workers who buy kamagra canada cooperate with a U.S. Department of Labor investigation of the bakery’s employment practices, a federal court in Hartford has ordered in a consent preliminary injunction obtained by the department.The department’s Wage and Hour Division investigated Padaminas NY Bakery II LLC and owner Pedro Coelho for potential Fair Labor Standards Act violations. Shortly after buy kamagra canada the investigation began, the department alleged that Coelho met with his employees on two occasions.

The department’s complaint states that during those meetings, Coelho told his employees he would fire them and report them to immigration authorities if they cooperated with the investigation. The complaint also alleges that defendants blacklisted a former employee they believed filed a complaint with the buy kamagra canada division. The U.S.

District Court for the District of Connecticut in Hartford issued a consent order prohibiting the bakery and its owner from retaliating against current and former employees and obstructing the division’s investigation. Due to the potential for buy kamagra canada ongoing retaliation by the defendants, the department sought and obtained the consent preliminary injunction. The injunction prohibits the defendants from taking any of the following actions in violation of the FLSA.

Terminating or threatening to terminate any buy kamagra canada employee. Reporting or threatening to report any employee or former employee to immigration authorities. Threatening to have any employee or former employee deported.

Using against buy kamagra canada any employee or former employee their immigration status, citizenship, work authorization status or lack of government documents (including a driver’s license). Disparaging or threatening to disparage any employee or former employee to other employers. Blacklisting any employee buy kamagra canada or former employee.

Making any employees’ working conditions less favorable, including by reducing any employee’s hours of work or pay. Retaliating or discriminating against employees or former employees in any other way. Obstructing the division’s investigation buy kamagra canada of the defendants.

The consent injunction also requires the defendants to permit a division representative to notify all the defendants’ employees on paid working time of their FLSA rights, which includes their right to speak freely and honestly with the Wage and Hour Division without fear of retaliation, and provide a written notice of FLSA rights to all employees in a language they understand. €œThe Fair Labor Standards Act not only guarantees that employees receive all the wages they are due for the hours they work, it also forbids employers from retaliating against, punishing or blacklisting employees because they exercise their rights under the law,” said Wage and Hour Division District Director buy kamagra canada Donald Epifano in Hartford, Connecticut. €œKnowing and understanding the law can prevent violations from occurring in the first place.

We encourage employers and employees with questions about their respective responsibilities and rights to contact the Wage and Hour Division.” “The defendants’ alleged behavior is buy kamagra canada unlawful and extreme. Seeking to intimidate employees will not halt a Wage and Hour Division investigation. The U.S.

Department of Labor will, as in this case, respond with appropriate and expeditious buy kamagra canada legal action to protect employees’ rights and hold employers accountable for their retaliatory and obstructionist actions,” said regional Solicitor of Labor Maia Fisher in Boston. The division’s Hartford District Office is conducting the investigation. The department’s regional Office of the Solicitor is litigating the buy kamagra canada case.

Workers can call the Wage and Hour Division confidentially with questions – regardless of their immigration status – and the department can speak with callers in more than 200 languages. For more information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243). Learn more about buy kamagra canada the Wage and Hour Division, including a search tool to use if you think you may be owed back wages collected by the division.

Walsh v. Padaminas NY Bakery II LLC and owner Pedro Coelho Civil Action buy kamagra canada No. 3:21-cv-1051WASHINGTON, DC – On Aug.

18, workers at the General Motors’ Silao plant in Mexico voted to reject a proposed collective bargaining agreement, an action heralded as a win for the labor protections built into the United States-Mexico-Canada Agreement.The vote comes as a result of a first-of-its-kind comprehensive plan to remediate a past denial of freedom of association and collective bargaining rights for the workers at the plant, when irregularities were identified in an April 2021 collective bargaining buy kamagra canada legitimization vote. A result of the first self-initiated petition under USMCA’s Rapid Response Mechanism, the plan laid out steps to ensure workers at the facility were able to participate in a vote on their collective bargaining agreement free of interference. Mexican labor inspectors and observers from the International Labor Organization were at GM’s facilities in Silao two weeks prior to the vote and during the vote itself to ensure a fair process.

The Rapid Response Mechanism under the USMCA allows buy kamagra canada the U.S. To take expedited enforcement actions based on the actions of individual factories in Mexico that fail to comply with domestic freedom of association and collective bargaining laws. €œSecretary of Labor Marty Walsh fought buy kamagra canada hard for this result.

Now, thanks to the U.S.-Mexico-Canada Agreement labor protections, the workers at the General Motors’ Silao plant are able to exercise their voice in determining the future of their collective bargaining agreement,” said Deputy Undersecretary for International Affairs Thea Lee. €œThis is an example of successful collaboration between the department, the Office of the U.S. Trade Representative, and the buy kamagra canada government of Mexico.

The U.S. Government remains committed to working with the Mexican government to make sure our trade policies work for workers.” Nearly 6,000 workers voted during a period of 34 hours, and 2,623 voted yes for the collective bargaining agreement while 3,214 voted no buy kamagra canada. The “no" vote winning the majority of support means the current collective bargaining agreement will be nullified, and there will likely be a process set into motion for workers to choose the union they would like to represent them.

The Mexican labor inspectorate now has 20 working days to review and certify results. The second phase of Mexico’s historic labor reform buy kamagra canada starts on Oct. 1 in 13 states, including Guanajuato, which contains GM’s Silao facility.

Unions in Mexico need to legitimize all collective bargaining agreements by May 2023. Given the enormity of this task and importance to advancing union democracy, the GM Silao process serves as a good case study and provides critical information for Mexico to strengthen policies like the collective bargaining agreement legitimation protocol that are key to elevating worker voices. Learn more about the department’s International Labor Affairs Bureau..

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