Get Started >>. It is predicted symbicort 160mcg 4.5mcg inhaler price that climate change will cause around 250,000 additional annual deaths between 2030 and 2050. The combined effect of climate change, and increasing inequality, could lead to a more divided world. This could exacerbate the impact of symbicort 160mcg 4.5mcg inhaler price social and environmental determinants of health, for example, clean air.
Safe drinking water. Sufficient quantity and quality of food symbicort 160mcg 4.5mcg inhaler price. Secure shelter. And access to quality health and care services.ON THE RECORDProfessor Jan symbicort 160mcg 4.5mcg inhaler price Semenza said climate change would impact health.
ÂExtreme weather events such as heat or rising sea levels are modulated by a number of vulnerabilities, or factors, such as the human capital in the human population, social capital, financial capital, fiscal capital and natural capital. Exposure can cause injuries, symbicort 160mcg 4.5mcg inhaler price fatalities, drownings, heat- related mortality, morbidity, displacement. A whole slew of different kinds of risksâ. Semenza said a Matched Case Control Study was carried out between 1992 and 2012 in Denmark, Finland, Norway and Sweden to determine whether excess precipitation could mobilise and transport pathogens, symbicort 160mcg 4.5mcg inhaler price leading to water-borne outbreaks.
This showed there was an association between heavy precipitation events and water-borne outbreaks.Dr Hans Kluge, WHO, said. ÂThe relationship between health and economic development and social cohesion, is linked to symbicort 160mcg 4.5mcg inhaler price climate change. An economy of wellbeing is a fair and environmentally friendly society where everyone has his social safety protector and where health does not put on an economic burden but is a job creator.What citizens legitimately, and reasonably, expect from the health authorities is to guarantee the fundamental right to universal health coverage. But for that you need solidarity symbicort 160mcg 4.5mcg inhaler price.
If solidarity does not come from the heart, it should come from the brain because no-one is safe until everyone is safeâ.Hal Wolf, HIMSS, said. ÂThe stark realisation from anti inflammatory drugs is that borders have nothing to with the spread of disease and no-one is safe until symbicort 160mcg 4.5mcg inhaler price everyone is safe. We do not understand how to bring the most basic healthcare and the most basic service to each and every village, and every country, around the world. We are going to continue to create vulnerabilities that will start someplace else, spread across the borders and really put everyone in jeopardy, so this idea that strong economies will remain strong and invulnerable to symbicort 160mcg 4.5mcg inhaler price the hardships of individuals, who donât have the same capabilities, or luxuries, just isnât true.âHe said digital health might help.
ÂIt is one of the big equalisers. We will face shortages of primary care physicians and clinicians so we have to create, through digital health, some symbicort 160mcg 4.5mcg inhaler price of those equalisers, which can spread all the way down to the most basic phone in the most basic village and thatâs a positive step forward.â Professor Sam Shah, faculty of Future Health in the UK also recognised the potential impact of digital to help citizens access services. However, he questioned whether the right technology was reaching the right people but concluded that the digital divide was âprobably just a transitory stateâ. However, he warned that wider society was becoming increasingly divided symbicort 160mcg 4.5mcg inhaler price.
Âanti inflammatory drugs, if anything, has exacerbated, highlighted and exposed the widening of inequalities in society. The gap between symbicort 160mcg 4.5mcg inhaler price those who have and those who have not. The results of this are very different, in everything from life expectancy, outcomes and access to services.âShah said that climate change could cause a range of problems such as respiratory illness, cardiovascular disease, injuries, and premature death. He also symbicort 160mcg 4.5mcg inhaler price believed it would have an impact on mental health and wellbeing.
He said the wider social determinants of health, such as education, employment and housing, could significantly affect health, particularly mental health.Access sessions from the HIMSS &. Health 2.0 European Digital Conference 'On Demand' and find all the latest news and deveopments from the event here.Hyland, a Westlake, Ohio-based content services and enterprise imaging technology vendor, signed a definitive agreement to acquire content services platform Alfresco this week.The move follows Hyland's acquisition of German robotic process automation software developer Another Monday this past month."We continue to grow our business and advance our platform organically and via acquisitions," said Bill Priemer, president and CEO of Hyland, in a statement.WHY IT MATTERSHyland, which provides content services for a variety of industries â symbicort 160mcg 4.5mcg inhaler price including financial services, government, higher education, insurance and healthcare â has products in use at more than half of Fortune 100 companies, says the vendor.Its cloud-based, SaaS platform includes security features such as version control, data classification and at-rest data encryption, according to the company's website.Expected to close in the fourth quarter of 2020, Alfresco's entire business of cloud-native content services solutions for enterprises with large volumes of unstructured content will likely be managed under Hyland."With this acquisition Alfresco brings significant geographic and industry experience to Hyland as well as an open source community as a new source of product innovation," said Jay Bhatt, president and CEO of Alfresco. Another Monday, meanwhile, houses four complementary software products for automation, including tools for automatic process documentation, development, conduction and monitoring."The RPA market is an exciting and challenging space with rapid growth and a vast number of possible applications that organizations can easily combine and integrate for better and more flexible business processes support," said Hans Martens, CEO of Another Monday, in a statement."We see Hyland as the best fit to embed our RPA technology into their powerful automation platform, to truly implement easy, end-to-end automation for everyone," Martens continued.Hyland also this past month announced new enhancements to its platform, including updated mobile capabilities and an improved upgrade process.THE LARGER TRENDSusan deCathelineau, senior vice president of healthcare sales and services at Hyland, told Healthcare IT News earlier this year that unstructured information â such as clinical documents, narratives, consents and images â has largely been overlooked when it comes to interoperability concerns. She also pointed to artificial intelligence as a needed complement to physicians overwhelmed by data and noted that moving to the cloud was symbicort 160mcg 4.5mcg inhaler price an essential shift for the healthcare industry."The hesitancy that used to surround cloud adoption in healthcare now is being replaced by the realization of its ultimate inevitability.
Once again, this shift in mindset largely has to do with data overload," she said.Hyland had at the time recently acquired the blockchain-credentialing vendor LearningMachine, another in a string of acquisitions dating back years.ON THE RECORD"This acquisition will expand our global reach, enabling us to help more organizations achieve their digital transformation goals and become more informed, empowered and connected," said Priemer in a statement. Kat Jercich symbicort 160mcg 4.5mcg inhaler price is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.With the increasing spread of anti inflammatory drugs s, the governor of Arizona declared a moratorium on âelective surgeriesâ on March 19, 2020, in order to conserve hospital PPE supplies and build symbicort 160mcg 4.5mcg inhaler price capacity for potential anti inflammatory drugs patients needing hospitalization.The moratorium lasted for six weeks and was finally lifted on May 1, 2020.
The end of the suspension resulted in a backlog of more than 3,000 surgical procedures at Phoenix Childrenâs Hospital.THE PROBLEM HIMSS20 Digital Learn on-demand, symbicort 160mcg 4.5mcg inhaler price earn credit, find products and solutions. Get Started >>. âWhile it is true that elective surgeries are typically nonurgent, many of these are medically necessary and important for a childâs health and symbicort 160mcg 4.5mcg inhaler price well-being,â explained Dr. Vinay Vaidya, chief medical information officer at Phoenix Childrenâs Hospital.âBesides the delay in surgery for the patient, deferring all elective surgeries put a major financial strain on hospitals across the country.
The challenge symbicort 160mcg 4.5mcg inhaler price we had to address was how to resume the thousands of deferred surgeries, in addition to the new surgeries that were being added each day.âThese operations needed to be conducted in a timely and efficient manner while ensuring utmost safety for patients and healthcare providers. The scheduling of surgeries is a complex process that involves many players and requires a series of sequential and interdependent actions. The anti inflammatory drugs symbicort added magnitudes of complexity to each step in this process.âThis was an unprecedented situation that needed coordination across our entire system of care, from executive leadership to surgeons, anesthesiologists, nursing staff, operating room staff, schedulers, and ultimately patients and their families,â Vaidya said.âWe needed to build a common communication highway, based on information technology, that would provide real-time visibility through the entire scheduling process, and symbicort 160mcg 4.5mcg inhaler price to all stakeholders.âPROPOSALOnce the moratorium on elective surgeries was lifted, the process of rescheduling the backlog of more than 3,000 cases could begin.Clearly, what was needed was much more than simply throwing additional scheduling staff to work through the backlog one patient at a time, Vaidya said. Amidst a symbicort, staff had to rewrite the rules of how a surgical scheduling process would unfold.âBased on our previous experience of successfully using information technology in general, and data analytic dashboards in particular, it was evident at the very outset that we would need a similar approach to address the complex logistics,â he said.
ÂThe solution to resuming these surgeries was the symbicort 160mcg 4.5mcg inhaler price development of a proprietary dashboard, which could facilitate the entire triage of operations.âMEETING THE CHALLENGEGiven the challenges posed by anti inflammatory drugs, it was important to take into consideration a number of factors such as. The type of surgery, medical necessity and need for hospital/ICU stay, Vaidya explained. These elements needed to be balanced with the availability of PPE, adequate staffing, general and ICU bed availability, and ventilator availability, while ensuring the highest standards of safety for patients and hospital staff.âUsing a careful and well-planned approach, a surgical prioritization was developed and uniformly communicated to all surgical symbicort 160mcg 4.5mcg inhaler price teams,â Vaidya said. ÂTo support the assignment of surgical priority for 3,000-plus cases, a new dashboard was created.
This technology allowed each surgeon to review all their respective cases, and rapidly assign a symbicort 160mcg 4.5mcg inhaler price priority of high, medium or low to all the backlogged cases, as well as new cases.âAs this data was captured electronically, it was used to feed a separate dashboard created specifically for the schedulers, who found it easy to work through the list, based on surgical priority. This significantly improved the efficiency of the process, allowing staff to schedule a much higher number of patients each day than previously possible."The technology allowed for synergies across the enterprise in addressing the multifaceted challenges of resuming these operations."Dr. Vinay Vaidya, Phoenix Childrenâs HospitalâFor those symbicort 160mcg 4.5mcg inhaler price patients who were successfully scheduled for surgery, it was mandatory to test them for anti inflammatory drugs in the 72 hours preceding the date of surgery,â Vaidya noted.âThis process was also facilitated using the dashboard, which displayed the patients who were scheduled for anti inflammatory drugs testing, those who completed the test, and those who tested negative and were finally cleared for surgery. It also identified patients who tested positive for anti inflammatory drugs and needed to have their surgeries postponed.âThe entire end-to-end electronic process provided a single enterprise-wide view that allowed streamlined tracking of the patient throughout the multiple steps, not unlike that of an Amazon package, right from ordering to final delivery, Vaidya described.âThis also obviated the need for inefficient and time-consuming internal communication via emails, phone calls and spreadsheets between the surgeons, operating room staff and the schedulers,â Vaidya said.
ÂThe dashboard thus became the de facto central hub and the single source of truth, updated in real time, and extensively used symbicort 160mcg 4.5mcg inhaler price across the entire organization, from the frontline staff right up to senior leadership.âVaidya added that it is important to point out that the hospital was able to accomplish all of this very quickly.âWe already had in place an existing robust data warehouse structure that was receiving feeds from almost every information system used in the hospital, including live feeds from our EHR,â he said. ÂIn addition, much of the data needed for the dashboards had already been prepackaged into ready-to-use analysis cubes that had been previously built for other surgical projects preceding anti inflammatory drugs.âFinally, a couple of data analysts who were already proficient in rapidly building visually informative, interactive, actionable dashboards using Microsoftâs Power BI software, were able to deliver the dashboards in record time.RESULTSThe one success metric of this project that stands out is that the hospital was not only able to catch up quickly on the backlog of surgeries, but actually ended up performing 166 more surgeries in June and July of this year, compared with the same period last year â 4,199 versus 4,033 â Vaidya reported. This volume symbicort 160mcg 4.5mcg inhaler price speaks to the approach. An extensive use of data, analytics and dashboards to support every stage of the process, from surgeon prioritization to scheduling, testing and finally surgery, he added.âAmong the numerous types of surgeries performed during this challenging period, it is worth highlighting the results of our surgical volumes for two very complex surgeries,â he said.âPhoenix Childrenâs Hospital is nationally recognized as a center of excellence, and draws patients from all across the country for Pectus surgery, done to correct chest wall deformities, and Scoliosis surgery, to correct abnormal spine curvature.
Both are complex, long-duration surgeries that require a hospital stay, and are often planned months in advance to coincide with school summer break.âIn the case of Scoliosis surgery, the hospital succeeded in performing more surgeries this year during May through August compared with the same period last year, symbicort 160mcg 4.5mcg inhaler price 95 versus 91. The results for Pectus repair surgery were even more noteworthy. The surgical teams outperformed by 41% the symbicort 160mcg 4.5mcg inhaler price number of surgeries performed this year from May to August compared with the same period last year, 72 versus 51.âThe technology allowed for synergies across the enterprise in addressing the multifaceted challenges of resuming these operations,â Vaidya said. ÂThroughout this project, given that patient and provider safety was our highest priority, it is important to point out that no surgeon or anesthesiologist has tested positive for anti inflammatory drugs since surgery restarted â a testament to extensive safety protocols that were supported by dashboard usage at every stage.âADVICE FOR OTHERSThe success of this project no doubt depended on the collaboration and cooperation of many different teams, Vaidya said.
However, its foundation symbicort 160mcg 4.5mcg inhaler price was built upon the optimum use of data analytics, and dashboard technology, to provide precise, real-time, actionable information to all the key players, he added.âFortunately, most hospitals and health systems have developed their electronic capabilities over the last 10 years and are sitting on a trove of data,â he said.âEnsuring that the multiple, often disparate, information systems in a hospital setting all feed their data to a common data warehouse platform allows for optimum use of this data,â he explained. ÂMining the data, and providing it to frontline users via intuitive interfaces, turns it into actionable intelligence that produces results.âAs IT professionals, we have been promising our health providers that data can be used to produce higher quality outcomes,â he added. ÂUsing technology in symbicort 160mcg 4.5mcg inhaler price the resumption of surgeries is a perfect example of delivering on this promise.âTwitter. @SiwickiHealthITEmail the writer.
Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication.A woman living in Woodstock, New York, has filed suit against HealthAlliance Hospital and the information management vendor Ciox Health for allegedly declining to release her deceased husband's electronic health records in a non-paper format.The lawyer for the plaintiff, Sherry Russell, said that HealthAlliance Hospital's Broadway campus (formerly known as Kingston Hospital) has repeatedly directed her to Ciox for the records, which in turn allegedly told her she will have to pay 75 cents a page for photocopied paper versions."The maximum charge for electronic medical records under federal law is $6.50," said Russell's lawyer, John Fisher, in an interview with Healthcare IT symbicort 160mcg 4.5mcg inhaler price News. "But if they charge for the paper copy of the records, it could be thousands of dollars." According to a 2016 guidance from the U.S. Department of Health and Human Services, HIPAA-covered entities and business associates should either charge $6.50 to fulfill a record request or calculate fees symbicort 160mcg 4.5mcg inhaler price based on the labor cost of doing so.Earlier this year, the U.S. Department of Health and Human Services lifted that cap on fees when it comes to organizations charging third parties, such as law firms, when releasing copies of electronic records.
The fee symbicort 160mcg 4.5mcg inhaler price cap for patients, however, remains in place. Fisher says that Russell's alleged treatment is a violation of the HITECH Act, which â among other provisions â requires HIPAA-covered entities to provide patients with an electronic copy of their records. According to Fisher, after the death of Russell's husband, Charlie, symbicort 160mcg 4.5mcg inhaler price in October 2019, she requested his electronic health records in order to file a separate malpractice lawsuit against the hospital. Without the records, said Fisher, Russell cannot identify the physician involved in her husband's care.
Ciox said that it could not comment on pending litigation symbicort 160mcg 4.5mcg inhaler price. The Westchester Medical Health Network, of which HealthAlliance is a part, said it did not comment on ongoing litigation. WHY IT MATTERSAccording to Fisher, in March 2017, Charlie Russell underwent a chest X-ray as symbicort 160mcg 4.5mcg inhaler price part of a routine procedure. That X-ray showed a mass in his lung, but as Fisher told Healthcare IT News, neither Russell nor his wife were informed of it.
The next March, Fisher said, Russell went in for another chest symbicort 160mcg 4.5mcg inhaler price X-ray. This time, symbicort 160mcg 4.5mcg inhaler price doctors found a six-centimeter mass in his lung. Further imaging showed cancer in his brain and liver.Sherry Russell believes her husband's cancer could have been treated sooner, had the mass been identified and communicated about in 2017. She is planning to file a symbicort 160mcg 4.5mcg inhaler price medical malpractice lawsuit.
The deadline to sue is September 14, said Fisher, but Russell is relying on the electronic health records for her case. Fisher symbicort 160mcg 4.5mcg inhaler price said he has other clients with similar experiences at HealthAlliance concerning their records, and that clients whose cases qualify could join onto Russell's class-action suit filed this past week. "We know firsthand that there are others" that have experienced problems obtaining their electronic health records, said Fisher. THE LARGER TREND The symbicort 160mcg 4.5mcg inhaler price HIPAA Privacy Right Rule of Access guarantees patient access to physical or digital copies of healthcare records â and noncompliant health systems can face hefty fines.
In 2019, Bayfront Health St. Petersburg had to pay the HHS symbicort 160mcg 4.5mcg inhaler price Office of Civil Rights $85,000 and promise remediation after failing to give a pregnant woman timely access to her medical records.Meanwhile, Ciox has been at the center of a number of lawsuits concerning the costs of electronic health records. In 2018, the company sued HHS over the $6.50 flat fee Fisher invoked, saying that it "bears no rational relationship to the actual costs associated with processing such requests." HHS, in turn, said that it couldn't actually enforce that flat fee against Ciox, because Ciox is a business associate, not a covered entity.This lawsuit eventually led to the agency lifting the cap on fees for third-party organizations' requests for records. And last year, Ciox Health and the Wisconsin-based Aurora Health paid $35.4 million to settle a class-action lawsuit that accused the companies of overcharging for symbicort 160mcg 4.5mcg inhaler price records requests.Studies have shown other hospitals not complying with the HHS-recommended $6.50, with one reportedly charging more than $500 for a 200-page record.
ON THE RECORD HealthAlliance, said Fisher, is "stonewalling our client and affecting her ability to bring a lawsuit." Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.While some of the more obvious barriers to digital therapeutics adoption in Europe have come crashing down recently, adoption is still hampered by cultural momentum. That was the conclusion of a group of digital therapeutics stakeholders who presented at HIMSS &.
Health 2.0 Europe Digital Event today, in a session moderated by YourCoach Health chairman and COO Eugene Borukhovich.âOnce a product is CE Marked, has all the clinical evidence, has gone through even an HTA process, that even isnât enough,â said Jessica Shull, European lead at the Digital Therapeutics Alliance. ÂSo what weâre looking at is countries where there are these frameworks, products have been approved, theyâve been shown to be effective, theyâve even been shown to have healthy economic data, but physicians still arenât prescribing at the rates that we would hope.âA number of European governments have rolled-out the red carpet for digital therapeutics, including Germany, which has announced broad reimbursement for digital therapeutics. HIMSS20 DigitalLearn on-demand, earn credit, find products and solutions. Get Started >>.
ÂAll eyes are on Germany,â Borukhovich said. ÂThereâs a lot of entrepreneurs and large companies that are saying âCool, weâre going to get reimbursed, letâs hop on over to Germany.â But I know the pictureâs not that simple.ââThatâs what we wanted,â Julia Hagen, director, regulatory and politics, at Health Innovation Hub. ÂWe want to attract great digital solutions to the German healthcare system. So yes, welcome.
Come on over.âThe rest of the panelists represented people who either used or made digital therapeutics. Ken Cahill, CEO of digital mental health company SilverCloud, Alejandro Suero, whose company ReHand offers a digital therapeutic for physical rehab for hand injuries, and Dr César Morcillo Serra, medical director of internal medicine at Sanitas Digital Hospital.Panelists agreed on two major takeaways for how to improve adoption of digital therapeutics. The need to integrate these new devices into old workflows and processes and the importance of working with providers.âDigital transformation must focus on the patient and the healthcare professionals, because as you know people and culture are the main barrier for this kind of transformation,â Serra said. ÂWe must focus on how to prescribe these digital tools to help our patients.
Everything must help with these workflows â not giving us more work, but trying to help us.âAs such, Serra encouraged digital therapeutics innovators to focus on chronic conditions, which take up so much of the time of physicians like him.Sueroâs chosen focus â hand injuries, are a $5.8 billion per year problem, he said, and one that doesnât lend itself well to the intermittent contact of traditional medicine.To bring providers on board, Shull shared that the DtX alliance is working with medical societies as well as creating webinars and continuing education opportunities. Cahill has another approach. SilverCloud has found success by getting them invested first as patients.âOne of the most powerful workstreams is to deploy the programme within the health systemâs own staff,â he said. ÂTheyâre one of the most heavily challenged workforces that are out there in terms of stigma for mental healthcare, in terms of actually being able to take time away and go and do it.
So them almost taking their own medicine has been a huge way of creating champions within these organisations.âPanelists warned that there are other challenges still awaiting digital therapeutics beyond adoption."The ongoing challenge of EHR interoperability, for instance, will impact the long-term success of digital health and digital therapeutics," Shull said. "Because of the influx of data digital health products can produce, most legacy EHR systems aren't yet enabled to incorporate data from several sources at once.âAdditionally, building a clinical evidence base is no small thing, Suero and Cahill said.âThe challenge in terms of building that evidence base is to build it in the right way,â Cahill said. If you are building an evidence-base, it has to mirror what the protocol design was, what the research design was. It may seem simple, but in fact itâs reasonably complicated.
¦ Weâve got five active randomised control trials today even though weâre 10 years out [of launch]. That will be one of the biggest challenges for us to show that proof.âBut one thing is for sure. Itâs time to move beyond the rudimentary conversations about digital therapeutics and get into the nitty-gritty.âI want to see real discussion, not about the broad âShould we have a data privacy discussion?. Â, but I want to get the discussion to the level where itâs about the medical application and its effects and not this general digital health blah blah is it great or not and can we stop it?.
 Hagen said. ÂNo, we canât.âRegister now to attend the HIMSS &. Health 2.0 European Digital Conference and keep up with the latest news and deveopments from the event here..
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22 October, symbicort coupon for uninsured where to buy generic symbicort 2020. The National Clinical Terminology Service (NCTS) is pleased to announce that the symbicort coupon for uninsured October combined release of SNOMED CT®-AU and the Australian Medicines Terminology (AMT) is now available to registered users from the NCTS website. Important InformationDocument Library updateThe following resources have been added to the Document Library. Please refer to the NCTS Document Library Release Note v2.24 in Recent Updates for further symbicort coupon for uninsured details EventsAMT Support Group meetingThe AMT Support Group is an open forum to provide an opportunity for individuals to participate in the ongoing development of the AMT. The next meeting will be held via teleconference on Tuesday 10th November 2:00-3:30pm (AEDT).
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You can contact us by completing the online support request form, emailing [email protected], or calling 1300 901 001.Thank you for your continued support.21 October, symbicort 160mcg 4.5mcg inhaler price 2020. Sydneyâs five million residents will soon have access to electronic prescriptions, including communities from Hornsby shire in the north, to the city of Campbelltown in the south and the city of Penrith in the west. This follows the roll out symbicort 160mcg 4.5mcg inhaler price across all of Victoria in September. If a patient wants an electronic prescription from their doctor, rather than a paper prescription, the doctor selects this option in their software when creating the prescription and the patient will http://research.ukactive.com/moving-at-scale/ immediately receive an SMS or email.
The patient then sends or takes this to their preferred symbicort 160mcg 4.5mcg inhaler price pharmacy.The SMS or email contains a QR code âtokenâ that unlocks the electronic prescription from a secure, encrypted electronic prescription delivery service. Once scanned, the token allows the pharmacist to view the prescription and dispense the medicine.Australian Digital Health Agency CEO Amanda Cattermole said, âThere has been significant uptake of electronic prescriptions since they were first made available in May. Since then, nearly 400,000 electronic prescriptions have been received by patients.âVictoria already has access to electronic prescriptions and Sydney will roll out this month, followed by a staged expansion across the rest of Australia.To prepare for electronic prescriptions, more than 13,000 healthcare providers have symbicort 160mcg 4.5mcg inhaler price attended online training and education sessions run by the Agency. Further support and advice has been provided by clinical peak bodies, including the Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine (ACRRM), the Pharmacy Guild of Australia (PGA) and the Pharmaceutical Society of Australia (PSA).
Software providers have also provided masterclasses to their health professional customers.This collaboration means that when electronic prescriptions are available in your community, doctors and pharmacists will be prepared and able to support their patients.Western Sydney symbicort 160mcg 4.5mcg inhaler price pharmacy owner and NSW Pharmacy Guild and National Councillor Catherine Bronger said, âCommunity pharmacies across Sydney have been working to upgrade their dispensing software and review their in-pharmacy workflow to get ready for electronic prescriptions. The Guild looks forward to further releases of electronic prescriptions functionality providing more convenience for patients, especially those who are on multiple medicines.â Future software enhancements in 2020 include the Active Script List (ASL), which is a token management solution.Electronic prescriptions are an symbicort 160mcg 4.5mcg inhaler price alternative to paper prescriptions. People should check if their preferred pharmacy is ready to dispense electronic prescriptions before requesting an electronic prescription from their doctor. For further details on electronic prescribing in NSW, here.For a summary of all legal forms symbicort 160mcg 4.5mcg inhaler price of prescriptions in NSW, here.Media contactAustralian Digital Health Agency Media TeamMobile.
0428 772 421Email. [email protected] symbicort 160mcg 4.5mcg inhaler price About the Australian Digital Health AgencyThe Agency is tasked with improving health outcomes for all Australians through the delivery of digital healthcare systems, and implementing Australiaâs National Digital Health Strategy â Safe, Seamless, and Secure. Evolving health and care to meet the needs of modern Australia in collaboration with partners across the community. The Agency is the System Operator of My Health Record, and provides leadership, coordination, and delivery of a collaborative symbicort 160mcg 4.5mcg inhaler price and innovative approach to utilising technology to support and enhance a clinically safe and connected national health system.
These improvements will give individuals more control of their health and their health information, and support healthcare providers to deliver informed healthcare through access to current clinical and treatment information. Further information symbicort 160mcg 4.5mcg inhaler price. Www.digitalhealth.gov.auMedia release - Electronic prescriptions roll out expands to Metropolitan Sydney.pdf.
Before using Budesonide+Formoterol tell your doctor about all other medicines you use, especially:
How to symbicort 160 cite this article:Singh OP http://www.pmsneesby.com/2018/03/08/sanctum-sanctorum/. Mental health in diverse India. Need for symbicort 160 advocacy. Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of.
We have diversity in terms of geography â From the Himalayas to the symbicort 160 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 symbicort 160 of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes.
There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] symbicort 160 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 symbicort 160 insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India.
The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders symbicort 160. This may be due to lead toxicity, nutritional status, and perinatal issues.
Higher rates symbicort 160 of depression and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the symbicort 160 presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.
The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1â5 lakhs, symbicort 160 it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed symbicort 160 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 symbicort 160 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 symbicort 160 Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers. Similarly, at organizational level, the symbicort 160 Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from âMental Hai Kyaâ to âJudgemental Hai Kya.â In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.
The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as migrant symbicort 160 laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting the role of these symbicort 160 factors on mental health.
References 1.Compton MT, Shim RS. The social symbicort 160 determinants of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.
National Mental Health Survey of symbicort 160 India, 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.
129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.
The Global Burden of Disease Study 1990â2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.
2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].
5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.
AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses.
Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N.
Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as âa culturally determined idiom of distress.â It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.
The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords.
Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.
President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.
His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.
Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore â Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.
Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.
Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term âDhatâ was taken from the Sanskrit language, which is an important word âDhatuâ and has known several meanings such as âmetal,â a âmedicinal constituent,â which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for âloss of semenâ, and the DS is a well-known âculture-bound syndrome (CBS).â[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions âwaste of bodily humorsâ being linked to the âloss of Dhatus.â[5] Semen has even been mentioned by Aristotle as a âsoul substanceâ and weakness associated with its loss.[6] This has led to a plethora of beliefs about âfood-blood-semenâ relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to âanxiety for loss of semenâ is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.
Tiwari et al.[22] mentioned in their study that âculture is closely associated with mental disorders through social and psychological activities.â With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a âCultural Variantâ of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.
Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.
There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.
Depression continued to be reported as the most common association of DS in many studies.[25],[26] This âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.
He also mentions that the underlying âemotional distress and cultural contextsâ are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of âmood disordersâ can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a âcultural phenotypeâ of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.
Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.
A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.
The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.
The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as âsemen loss syndromeâ by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with âsemen loss anxietyâ suffer from a myriad of psychosexual symptoms, which have been attributed to âloss of vital essence through semenâ (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.
Most commonly associated symptoms were found as per score â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.
Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.
Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.
The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing âDhatâ in urine.
They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of âdhatâ in urine, attributed to excessive masturbation, extramarital and premarital sex.
Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.
60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for âDhatâ items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.
This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing âDhatâ multiple times a week. Among them, nearly 60% passed almost a spoonful of âDhatâ each time during a loss. This work on sexual disorders reported that the passage of âDhatâ was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).
Mostly, the participants experienced passage of Dhat as ânight fallsâ (60.1%) and âwhile passing stoolsâ (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the âloss of Dhat.â The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.
The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.
The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.
A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very âprecious,â needs preservation, and masturbation is a malpractice.
Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.
About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.
Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.
They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15â50 years of age, educated up to mid-school and mostly from a rural background.
Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16â23 years).
The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to âloss of something preciousâ, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and âDhatâ in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.
More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).
Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.
Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.
Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.
Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.
The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).
About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.
The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).
Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16â20 years (34%) followed by 21â25 years (28%), greater than 30 years (26%), 26â30 years (10%), and 11â15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.
Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).
Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18â25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.
Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.
Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.
Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.
Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.
As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal âsupplements,â etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.
Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology http://controlmyproject.com/?p=1 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 âpureâ variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right âplaceâ for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.
While ICD-10 considers DS under âother nonpsychotic mental disordersâ (F48), DSM-V mentions it only in appendix section as âcultural concepts of distressâ not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a âtrue syndrome.â[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural âidiomâ of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the ânicheâ of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader ânarrativeâ of depression.
In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric âconstructâ which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its âseparateâ existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.
It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a âbird's eyeâ view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.
Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.
Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India. Training and Training Centres. 2nd ed.
753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10.
[PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting. Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S.
DhÄt syndrome. A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.
Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In. Kleinman A, Lin TY, editors.
Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland. D Reidel Publishing Co. 1980.
P. 357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.
A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N. Dhat syndrome.
A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems.
Indian J Behav Sci 1995;5:58-63. 11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.
Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes. The story of Dhat syndrome.
Br J Psychiatry 2004;184:200-9. 13.Khan N. Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57.
[Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS. Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.
Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66. 16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S.
Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. Oman Med J 2017;32:251-5. 17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities.
PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017. 18.Kar SK.
Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45. [Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G.
Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10. 20.Shakya DR. Dhat syndrome.
Study of clinical presentations in a teaching institute of eastern Nepal. J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states.
Br J Psychiatry 1973;123:299-306. 22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview.
J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R. Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre.
J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome. Is it a distinct clinical entity?.
A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC. 'Dhat' syndrome â A useful clinical entity.
Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y. Semen-loss syndrome. A comparison between Sri Lanka and Japan.
American J Psychotherapy 1991;45:14-20. 27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.
Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P. Is Dhat syndrome indeed a culturally determined form of depression?. Indian J Psychol Med 2015;37:107-9.
29.Prakash O, Kar SK. Dhat syndrome. A review and update. J Psychosexual Health 2019;1:241-5.
30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.
31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 32.Paris A.
Dhat syndrome. A review. Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP.
Dhat syndrome. A review of the world literature. Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, MartÃn-Santos R.
Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8. 35.Kar SK, Sarkar S.
Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation.
The ICD-10, Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva. World Health Organisation.
1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome. A functional somatic syndrome of the Indian subcontinent?.
Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN. Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53.
39.Clyne MB. Indian patients. Practitioner 1964;193:195-9. 40.Yap PM.
The culture bound reactive syndrome. In. Caudil W, Lin T, editors. Mental Health Research in Asia and the Pacific.
Honolulu. East West Center Press. 1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al.
Problems in medical practice. A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.
Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A. Dhat syndrome and its social impact.
Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK. A study of male potency disorders. Indian J Psychiatry 1977;19:13-8.
[Full text] 45.Behere PB, Natraj GS. Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.
[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22. [PUBMED] [Full text] 47.Bhatia MS, Malik SC.
Dhat syndrome â 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 &.
51.Carstairs GM. Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.
52.Carstairs GM. The Twice Born. Bloomington. Indiana University Press.
1961. 53.Carstairs GM. Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972.
Br J Psychiatry 1973;123:271-7. 54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.
[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update. Indian J Psychiatry 2010;52:S260-3.
56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V.
Current nosology of Dhat syndrome and state of evidence. Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.
DSM-5. Washington. DC. American Psychological Association.
2013. 59.Yasir Arafat SM. Dhat syndrome. Culture bound, separate entity, or removed.
J Behav Health 2017;6:147-50. 60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.
Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis. Adv Psychosom Med 2013;33:15-30.
62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support.
None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.
How to symbicort 160mcg 4.5mcg inhaler price cite this visit this site right here article:Singh OP. Mental health in diverse India. Need for advocacy symbicort 160mcg 4.5mcg inhaler price. Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of.
We have diversity symbicort 160mcg 4.5mcg inhaler price in terms of geography â From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, symbicort 160mcg 4.5mcg inhaler price health infrastructure, child mortality, and other sociodemographic development indexes.
There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders. This may be due to lead toxicity, nutritional status, and perinatal issues.
Higher rates of depression symbicort 160mcg 4.5mcg inhaler price and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found symbicort 160mcg 4.5mcg inhaler price to be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.
The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we symbicort 160mcg 4.5mcg inhaler price look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1â5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from âMental Hai Kyaâ to âJudgemental Hai Kya.â In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.
The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials symbicort 160mcg 4.5mcg inhaler price 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 symbicort 160mcg 4.5mcg inhaler price inequality, our weapon is research highlighting the role of these factors on mental health.
References 1.Compton MT, Shim RS. The social determinants of symbicort 160mcg 4.5mcg inhaler price mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.
National Mental Health Survey of India, symbicort 160mcg 4.5mcg inhaler price 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.
129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.
The Global Burden of Disease Study 1990â2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.
2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].
5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.
AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses.
Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N.
Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as âa culturally determined idiom of distress.â It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.
The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords.
Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.
President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.
His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.
Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore â Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.
Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.
Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term âDhatâ was taken from the Sanskrit language, which is an important word âDhatuâ and has known several meanings such as âmetal,â a âmedicinal constituent,â which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for âloss of semenâ, and the DS is a well-known âculture-bound syndrome (CBS).â[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions âwaste of bodily humorsâ being linked to the âloss of Dhatus.â[5] Semen has even been mentioned by Aristotle as a âsoul substanceâ and weakness associated with its loss.[6] This has led to a plethora of beliefs about âfood-blood-semenâ relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to âanxiety for loss of semenâ is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.
Tiwari et al.[22] mentioned in their study that âculture is closely associated with mental disorders through social and psychological activities.â With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a âCultural Variantâ of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.
Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.
There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.
Depression continued to be reported as the most common association of DS in many studies.[25],[26] This âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.
He also mentions that the underlying âemotional distress and cultural contextsâ are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of âmood disordersâ can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a âcultural phenotypeâ of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.
Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.
A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.
The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.
The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as âsemen loss syndromeâ by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with âsemen loss anxietyâ suffer from a myriad of psychosexual symptoms, which have been attributed to âloss of vital essence through semenâ (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.
Most commonly associated symptoms were found as per score â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.
Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.
Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.
The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing âDhatâ in urine.
They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of âdhatâ in urine, attributed to excessive masturbation, extramarital and premarital sex.
Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.
60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for âDhatâ items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.
This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing âDhatâ multiple times a week. Among them, nearly 60% passed almost a spoonful of âDhatâ each time during a loss. This work on sexual disorders reported that the passage of âDhatâ was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).
Mostly, the participants experienced passage of Dhat as ânight fallsâ (60.1%) and âwhile passing stoolsâ (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the âloss of Dhat.â The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.
The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.
The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.
A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very âprecious,â needs preservation, and masturbation is a malpractice.
Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.
About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.
Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.
They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15â50 years of age, educated up to mid-school and mostly from a rural background.
Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16â23 years).
The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to âloss of something preciousâ, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and âDhatâ in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.
More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).
Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.
Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.
Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.
Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.
The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).
About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.
The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).
Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16â20 years (34%) followed by 21â25 years (28%), greater than 30 years (26%), 26â30 years (10%), and 11â15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.
Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).
Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18â25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.
Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.
Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.
Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.
Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.
As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal âsupplements,â etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.
Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.
Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.
Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization.
Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the âpureâ variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right âplaceâ for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.
While ICD-10 considers DS under âother nonpsychotic mental disordersâ (F48), DSM-V mentions it only in appendix section as âcultural concepts of distressâ not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a âtrue syndrome.â[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural âidiomâ of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the ânicheâ of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader ânarrativeâ of depression.
In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric âconstructâ which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its âseparateâ existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.
It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a âbird's eyeâ view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.
Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.
Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India. Training and Training Centres. 2nd ed.
753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10.
[PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting. Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S.
DhÄt syndrome. A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.
Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In. Kleinman A, Lin TY, editors.
Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland. D Reidel Publishing Co. 1980.
P. 357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.
A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N. Dhat syndrome.
A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems.
Indian J Behav Sci 1995;5:58-63. 11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.
Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes. The story of Dhat syndrome.
Br J Psychiatry 2004;184:200-9. 13.Khan N. Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57.
[Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS. Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.
Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66. 16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S.
Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. Oman Med J 2017;32:251-5. 17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities.
PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017. 18.Kar SK.
Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45. [Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G.
Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10. 20.Shakya DR. Dhat syndrome.
Study of clinical presentations in a teaching institute of eastern Nepal. J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states.
Br J Psychiatry 1973;123:299-306. 22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview.
J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R. Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre.
J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome. Is it a distinct clinical entity?.
A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC. 'Dhat' syndrome â A useful clinical entity.
Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y. Semen-loss syndrome. A comparison between Sri Lanka and Japan.
American J Psychotherapy 1991;45:14-20. 27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.
Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P. Is Dhat syndrome indeed a culturally determined form of depression?. Indian J Psychol Med 2015;37:107-9.
29.Prakash O, Kar SK. Dhat syndrome. A review and update. J Psychosexual Health 2019;1:241-5.
30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.
31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 32.Paris A.
Dhat syndrome. A review. Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP.
Dhat syndrome. A review of the world literature. Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, MartÃn-Santos R.
Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8. 35.Kar SK, Sarkar S.
Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation.
The ICD-10, Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva. World Health Organisation.
1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome. A functional somatic syndrome of the Indian subcontinent?.
Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN. Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53.
39.Clyne MB. Indian patients. Practitioner 1964;193:195-9. 40.Yap PM.
The culture bound reactive syndrome. In. Caudil W, Lin T, editors. Mental Health Research in Asia and the Pacific.
Honolulu. East West Center Press. 1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al.
Problems in medical practice. A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.
Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A. Dhat syndrome and its social impact.
Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK. A study of male potency disorders. Indian J Psychiatry 1977;19:13-8.
[Full text] 45.Behere PB, Natraj GS. Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.
[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22. [PUBMED] [Full text] 47.Bhatia MS, Malik SC.
Dhat syndrome â 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 &.
51.Carstairs GM. Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.
52.Carstairs GM. The Twice Born. Bloomington. Indiana University Press.
1961. 53.Carstairs GM. Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972.
Br J Psychiatry 1973;123:271-7. 54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.
[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update. Indian J Psychiatry 2010;52:S260-3.
56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V.
Current nosology of Dhat syndrome and state of evidence. Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.
DSM-5. Washington. DC. American Psychological Association.
2013. 59.Yasir Arafat SM. Dhat syndrome. Culture bound, separate entity, or removed.
J Behav Health 2017;6:147-50. 60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.
Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis. Adv Psychosom Med 2013;33:15-30.
62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support.
None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.
When we took the editorship of Evidence-Based Mental buy symbicort usa Health (EBMH) at the is symbicort safe end of 2013, we set two main objectives. To promote and embed an evidence-based medicine (EBM) approach into daily mental health clinical is symbicort safe practice, and to get an impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lot.EBM has been is symbicort safe around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains.
The best is symbicort safe available evidence, the clinical state and circumstances, and patientâs preferences and values. EBM and EBMH have since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the poor is symbicort safe quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily â¦IntroductionQuality-adjusted life years (QALYs) have been increasingly used in is symbicort safe general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death).
QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence is symbicort safe in the UK. While the responsiveness is symbicort safe of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-Ã -vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) is symbicort safe for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.
This study, therefore, attempts to link the depression-specific measure onto the generic measure of is symbicort safe health in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded is symbicort safe patients if they had missing data in either of the two scales at baseline or at endpoint. We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, is symbicort safe 2=some/moderate problems or 3=extreme problems/unable to do.
This produces is symbicort safe 3Ë5=243 different health states, ranging from no problem at all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full is symbicort safe health that they would be willing to sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to minus values=worse than death bounded is symbicort safe by â1.
The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been is symbicort safe produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, is symbicort safe the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0â27. The instrument has demonstrated excellent reliability, validity and responsiveness.
The cut-offs have been proposed as 0â4, 5â9, 10â14, 15â19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated is symbicort safe Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were â¥0.3 and<0.7 and strong if scores were â¥0.7.17 Correlations â¥0.3 have been recommended to establish linking.18 We then is symbicort safe applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimerâs disease.14 20â22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package is symbicort safe equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1).
Three studies is symbicort safe included only patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the studies is symbicort safe administered EQ-5D-3L. PHQ-9 scores were converted from the BDI-II in three studies24â26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no is symbicort safe depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5â¤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10â¤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15â¤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20â¤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearmanâs correlation coefficient between the PHQ-9 and the EQ-5D scores was r=â0.29 at baseline, increased to r=â0.50 after intervention and was r=â0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint.
Figure 2 is symbicort safe shows the same between their change scores. Table 1 summarises the correspondences between the two scales.PHQ-9 is symbicort safe and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure is symbicort safe 1 PHQ-9 and EQ-5D total scores at baseline and endpoint.
EQ-5D,Euro-Qol Five Dimensions is symbicort safe. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol is symbicort safe Five Dimensions. PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D is symbicort safe change scores.
EQ-5D,Euro-Qol Five is symbicort safe Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28â30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression corresponded with EQ-5D-3L index is symbicort safe values of 0.9â0.8, mild major depression with 0.8â0.7, moderate depression with 0.7â0.5 and severe depression with 0.6â0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, is symbicort safe 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression.
The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression. One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 is symbicort safe 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or is symbicort safe endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.
It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically is symbicort safe expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the is symbicort safe average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate is symbicort safe average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY.
If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, is symbicort safe the gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic is symbicort safe drawing to help understand the calculation of QALYs based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1â3 dollars and is symbicort safe a 1-year prescription costs US$400â1200 dollars, or if 8â16 sessions of psychotherapy cost US$1600â3200 dollars, both therapies would be deemed largely cost-effective.
An individualâs is symbicort safe decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient is symbicort safe may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months is symbicort safe while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.
If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be is symbicort safe expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly is symbicort safe curvilinear but the calculation will be similar. EQ-5D, Euro-Qol Five is symbicort safe Dimensions.
PHQ-9, Patient Health Questionnaire-9 is symbicort safe. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding is symbicort safe with EQ-5D index value of 0.5. Then they is symbicort safe may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line).
If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over is symbicort safe the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note is symbicort safe that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.
EQ-5D,Euro-Qol Five is symbicort safe Dimensions. PHQ-9, PatientHealth Questionnaire-9 is symbicort safe. QALY, quality-adjustedlife years.Several caveats is symbicort safe should be considered when interpreting the results. First, our sample was limited to participants of trials of iCBT.
It may be argued that the is symbicort safe results, therefore, would not apply to patients with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D is symbicort safe were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able to compare PHQ-9 is symbicort safe to EQ-5D-3L only.
The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important is symbicort safe strengths. First, our sample included patients with subthreshold depression is symbicort safe and major depression and from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample is symbicort safe received iCBT or control interventions including care as usual.
Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their is symbicort safe impacts, but our estimates, arguably independent of major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at is symbicort safe the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this is symbicort safe IPD is restricted due to data sharing agreements with the research institutes where the studies were conducted.
IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..
When we took the editorship of symbicort 160mcg 4.5mcg inhaler price Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main http://h2owireless.de/produkt/vneck-tee/ objectives. To promote symbicort 160mcg 4.5mcg inhaler price and embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lot.EBM has been around symbicort 160mcg 4.5mcg inhaler price for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains.
The best available evidence, the clinical symbicort 160mcg 4.5mcg inhaler price state and circumstances, and patientâs preferences and values. EBM and EBMH have since symbicort 160mcg 4.5mcg inhaler price continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily â¦IntroductionQuality-adjusted life symbicort 160mcg 4.5mcg inhaler price years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death).
QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across symbicort 160mcg 4.5mcg inhaler price different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK. While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been symbicort 160mcg 4.5mcg inhaler price generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-Ã -vis other medical conditions on the one symbicort 160mcg 4.5mcg inhaler price hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.
This study, therefore, attempts to link the depression-specific symbicort 160mcg 4.5mcg inhaler price measure onto the generic measure of health in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if symbicort 160mcg 4.5mcg inhaler price they had missing data in either of the two scales at baseline or at endpoint. We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, symbicort 160mcg 4.5mcg inhaler price each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do.
This produces 3Ë5=243 different health states, ranging from no problem at all in any dimension (11111) to severe problems on symbicort 160mcg 4.5mcg inhaler price all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked symbicort 160mcg 4.5mcg inhaler price to give the relative length of time in full health that they would be willing to sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range symbicort 160mcg 4.5mcg inhaler price between 1=full health and 0=death to minus values=worse than death bounded by â1.
The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe symbicort 160mcg 4.5mcg inhaler price included any validated depression severity measures. The scale scores were converted into the symbicort 160mcg 4.5mcg inhaler price most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0â27. The instrument has demonstrated excellent reliability, validity and responsiveness.
The cut-offs symbicort 160mcg 4.5mcg inhaler price have been proposed as 0â4, 5â9, 10â14, 15â19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were â¥0.3 and<0.7 and strong if scores were â¥0.7.17 Correlations â¥0.3 have been recommended to establish linking.18 We then symbicort 160mcg 4.5mcg inhaler price applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimerâs disease.14 20â22 We analysed all trials collectively rather than by trial to maximise the symbicort 160mcg 4.5mcg inhaler price sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1).
Three studies included only patients with major depressive disorder symbicort 160mcg 4.5mcg inhaler price (MDD), one only patients with subthreshold depression and the remaining three included both. All the symbicort 160mcg 4.5mcg inhaler price studies administered EQ-5D-3L. PHQ-9 scores were converted from the BDI-II in three studies24â26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5â¤PHQ-9 scores <10), 33.5% (820/2449) from mild depression symbicort 160mcg 4.5mcg inhaler price (10â¤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15â¤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20â¤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearmanâs correlation coefficient between the PHQ-9 and the EQ-5D scores was r=â0.29 at baseline, increased to r=â0.50 after intervention and was r=â0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint.
Figure 2 shows the same between symbicort 160mcg 4.5mcg inhaler price their change scores. Table 1 summarises the correspondences between the two scales.PHQ-9 and EQ-5D symbicort 160mcg 4.5mcg inhaler price total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position symbicort 160mcg 4.5mcg inhaler price data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline and endpoint.
EQ-5D,Euro-Qol Five symbicort 160mcg 4.5mcg inhaler price Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol Five Dimensions symbicort 160mcg 4.5mcg inhaler price. PHQ-9, Patient Health symbicort 160mcg 4.5mcg inhaler price Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.
EQ-5D,Euro-Qol Five symbicort 160mcg 4.5mcg inhaler price Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28â30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression symbicort 160mcg 4.5mcg inhaler price corresponded with EQ-5D-3L index values of 0.9â0.8, mild major depression with 0.8â0.7, moderate depression with 0.7â0.5 and severe depression with 0.6â0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies symbicort 160mcg 4.5mcg inhaler price using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression.
The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression. One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated symbicort 160mcg 4.5mcg inhaler price none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a symbicort 160mcg 4.5mcg inhaler price consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.
It is, therefore, reasonable to use the conversion table at baseline for relatively new symbicort 160mcg 4.5mcg inhaler price cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about symbicort 160mcg 4.5mcg inhaler price 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x symbicort 160mcg 4.5mcg inhaler price versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY.
If we assume that the symbicort 160mcg 4.5mcg inhaler price difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for symbicort 160mcg 4.5mcg inhaler price a schematic drawing to help understand the calculation of QALYs based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1â3 dollars and a 1-year prescription costs US$400â1200 dollars, or if 8â16 sessions of symbicort 160mcg 4.5mcg inhaler price psychotherapy cost US$1600â3200 dollars, both therapies would be deemed largely cost-effective.
An individualâs decision, by contrast, will and should be more symbicort 160mcg 4.5mcg inhaler price variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of symbicort 160mcg 4.5mcg inhaler price 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would symbicort 160mcg 4.5mcg inhaler price continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.
If we assume that the difference would eventually wear out over the course of the year due to symbicort 160mcg 4.5mcg inhaler price naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the symbicort 160mcg 4.5mcg inhaler price changes will be more smoothly curvilinear but the calculation will be similar. EQ-5D, Euro-Qol Five symbicort 160mcg 4.5mcg inhaler price Dimensions.
PHQ-9, Patient Health Questionnaire-9 symbicort 160mcg 4.5mcg inhaler price. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start symbicort 160mcg 4.5mcg inhaler price with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve symbicort 160mcg 4.5mcg inhaler price to EQ-5D score of 0.8 even if on placebo (dashed line).
If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the symbicort 160mcg 4.5mcg inhaler price year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a symbicort 160mcg 4.5mcg inhaler price schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.
EQ-5D,Euro-Qol Five symbicort 160mcg 4.5mcg inhaler price Dimensions. PHQ-9, PatientHealth symbicort 160mcg 4.5mcg inhaler price Questionnaire-9. QALY, quality-adjustedlife years.Several caveats should be considered when interpreting symbicort 160mcg 4.5mcg inhaler price the results. First, our sample was limited to participants of trials of iCBT.
It may be argued that the results, therefore, would not apply to patients with depression symbicort 160mcg 4.5mcg inhaler price undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D symbicort 160mcg 4.5mcg inhaler price were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we symbicort 160mcg 4.5mcg inhaler price were able to compare PHQ-9 to EQ-5D-3L only.
The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important symbicort 160mcg 4.5mcg inhaler price strengths. First, our symbicort 160mcg 4.5mcg inhaler price sample included patients with subthreshold depression and major depression and from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients symbicort 160mcg 4.5mcg inhaler price in our sample received iCBT or control interventions including care as usual.
Potential side symbicort 160mcg 4.5mcg inhaler price effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden symbicort 160mcg 4.5mcg inhaler price of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this IPD is restricted due to data sharing agreements with the research institutes where the symbicort 160mcg 4.5mcg inhaler price studies were conducted.
IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..
With thanks to symbicort aerosol 160 4.5 mcg act Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article.âFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.It is well established that prevention of cardiovascular diseases (CVDs) is based on optimization of lifestyle including abstinence from smoking, regular physical activity, and an optimal diet.1â3 Nevertheless, growing evidence suggests that some risk factors, such as air pollution4 and social isolation,5 cannot be modified by single individuals but only by a coordinated effort aimed to improve social care and healthcare organization. This is a Focus Issue on prevention and epidemiology assessing these important risk factors, which are beyond the reach of single individuals. It also provides novel information on the role of new biomarkers and of proteomics in risk stratification of CVDs and dementia.The first contribution is symbicort aerosol 160 4.5 mcg act a State of the Art Review entitled âReduction of environmental pollutants for prevention of cardiovascular disease. Itâs time to actâ by Thomas Münzel from the Johannes Gutenberg Universität in Mainz, Germany and colleagues.6 The authors note that environmental risk factors are increasingly recognized as important determinants of CVD.
While the contributions of diet, exercise, and smoking are well established, the contribution by factors such as noise and air pollution are often not acknowledged, symbicort aerosol 160 4.5 mcg act despite the recognition that they represent the two most common and pervasive environmental risk factors globally. Recent data indicate that air pollution-attributable premature deaths approach 9 million per year globally (mostly cardiovascular causes), accounting for a loss of life expectancy that rivals that of tobacco smoking. The health burden due to noise pollution is mostly based symbicort aerosol 160 4.5 mcg act on loss of healthy life years, amounting to several hundreds of millions of disability-adjusted life years per year. Importantly, health effects of both air pollution and traffic noise are observed at levels of exposure well below the regulatory thresholds, currently assumed to be safe.
Mechanistic evidence in animal models, natural intervention studies, and quasi-experimental studies with air pollution mitigation support a direct pathophysiological role for air pollution in CVD. In this current opinion, the epidemiological and mechanistic evidence in support of an association symbicort aerosol 160 4.5 mcg act between noise and air pollution with CVD and metabolic disease, and comprehensive mitigation measures, is discussed. Increased awareness of the health burden posed by these risk factors and incorporation in traditional medical guidelines will help propel legislation to reduce them and significantly improve cardiovascular health.In the era of personalized medicine, it is of utmost importance to be able to identify subjects at highest cardiovascular risk. To date, single biomarkers have failed to markedly improve estimation symbicort aerosol 160 4.5 mcg act of cardiovascular risk.
Using novel technology, simultaneous assessment of large numbers of biomarkers may hold promise to improve prediction.7 In a clinical research article entitled âImproved cardiovascular risk prediction using targeted plasma proteomics in primary preventionâ, Renate Hoogeveen from the University of Amsterdam in the Netherlands and colleagues compared a protein-based risk model with a model using traditional risk factors in predicting cardiovascular events in the primary prevention setting of the EPIC-Norfolk study, followed by validation in the PLIC cohort.8 Using the proximity extension assay, >350 proteins were measured in a nested caseâcontrol sample of â¼1500 individuals. Using tree-based ensemble and boosting methods, the authors constructed a protein-based prediction model, an optimized clinical risk model, and a model combining both symbicort aerosol 160 4.5 mcg act. In the derivation cohort (EPIC-Norfolk) they defined a panel of 50 proteins, which outperformed the clinical risk model in prediction of myocardial infarction, with an area under the curve (AUC) of 0.754 during a median follow-up of 20 years (Figure 1). The predictive value of the protein symbicort aerosol 160 4.5 mcg act panel was confirmed to be superior to the clinical risk model in the validation cohort (PLIC).
Figure 1Receiver operating characteristics of prediction models. (A) Prediction of events with protein, clinical risk, and the combined model in the derivation cohort. (B) Short-term prediction (<3 years) of events with protein, clinical risk, and the combined model symbicort aerosol 160 4.5 mcg act in the derivation cohort. (C) Prediction of events with protein, clinical risk, and the combined model in the validation cohort.
AUC, area symbicort aerosol 160 4.5 mcg act under the curve. ROC, receiver operating characteristic (from Hoogeveen RM, Belo Pereira JP, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw K-T, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using targeted symbicort aerosol 160 4.5 mcg act plasma proteomics in primary prevention. See pages 3998â4007).Figure 1Receiver operating characteristics of prediction models.
(A) Prediction of events with protein, clinical risk, and the combined model in the derivation cohort. (B) Short-term prediction (<3 years) of events with protein, clinical symbicort aerosol 160 4.5 mcg act risk, and the combined model in the derivation cohort. (C) Prediction of events with protein, clinical risk, and the combined model in the validation cohort. AUC, area under symbicort aerosol 160 4.5 mcg act the curve.
ROC, receiver operating characteristic (from Hoogeveen RM, Belo Pereira JP, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw K-T, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using symbicort aerosol 160 4.5 mcg act targeted plasma proteomics in primary prevention. See pages 3998â4007).The authors conclude that in a primary prevention setting, a proteome-based model outperforms a model comprising clinical risk factors in predicting the risk of cardiovascular events, but validation in a large prospective primary prevention cohort is required in order to address the value for future clinical implementation in guidelines. The manuscript is accompanied by an Editorial by Peter Ganz from the University of California San Francisco in California, USA and colleagues.9 The authors note that data accumulating in symbicort aerosol 160 4.5 mcg act ongoing studies will establish whether the great potential of proteomics to improve healthcare is fulfilled.The risk and burden of CVD are higher in homeless than in housed individuals, but population-based analyses are lacking.
In a clinical research article entitled âPrevalence, incidence, and outcomes across cardiovascular diseases in homeless individuals using national linked electronic health recordsâ, Amitava Banerjee from the University College London, UK and colleagues investigated prevalence, incidence, and outcomes across a range of specific CVDs among homeless individuals.10 Using linked UK primary care electronic health records and validated phenotypes, the authors identified â¼8500 homeless individuals aged â¥16 years between 1998 and 2019, and â¼32 000 age- and sex-matched housed controls. Comorbidities and risk factors were significantly more prevalent in homeless than in housed people. In addition, CVD prevalence, incidence, and 1-year mortality risk (adjusted hazard ratio 1.64) were higher in homeless than in housed people.The authors conclude that inclusion healthcare and social care strategies should reflect this high preventable and treatable burden observed in homeless people, which is increasingly important in the current symbicort aerosol 160 4.5 mcg act anti inflammatory drugs context. This manuscript is accompanied by an Editorial by Elias Mossialos and Sahan Jayawardana from the London School of Economics and Political Science in the UK.11 The authors note that close coordination is required between agencies and services to ensure a coherent pathway to address the needs of people at risk of becoming homeless.Dementia is a major global challenge for healthcare and social care in ageing populations.12 A third of all dementia cases may be preventable due to cardiovascular risk factors.
In a clinical research article entitled symbicort aerosol 160 4.5 mcg act âImpact of cardiovascular risk factors and genetics on 10-year absolute risk of dementia. Risk charts for targeted preventionâ, Ruth Frikke-Schmidt from the Rigshospitalet in Copenhagen, Denmark and colleagues note that intensive multidomain intervention trials targeting primarily cardiovascular risk factors show improved cognitive function in people at risk.13 Such interventions, however, would be expensive to implement in all individuals at risk, representing an unrealistic economic task for most societies. Therefore, a risk score identifying high-risk individuals symbicort aerosol 160 4.5 mcg act is warranted. In 61 500 individuals from two prospective cohorts of the Danish general population, the authors generated 10-year absolute risk scores for all-cause dementia from cardiovascular risk factors and genetics.
In both sexes, 10-year absolute risk of all-cause dementia increased with increasing age, number of symbicort aerosol 160 4.5 mcg act apolipoprotein E (APOE) É4 alleles, number of genome-wide association study (GWAS) risk alleles, and cardiovascular risk factors. The highest 10-year absolute risks of all-cause dementia seen in female smokers who had diabetes, low education, APOE É44 genotype, and 22â31 GWAS risk alleles were 6, 23, 48, and 66% in those aged 50â59, 60â69, 70â79, and 80â100, respectively. Corresponding values for men were 5, 19, 42, and 60%, respectively.The authors conclude that 10-year absolute risk charts for dementia will facilitate identification of high-risk individuals, those who probably will benefit the most from an early intervention against cardiovascular risk factors. The manuscript is accompanied by an Editorial by Andrew Sommerlad from the University College London in the UK, and Andrew Sommerlad.14 The authors note that the economic, social, and individual costs of dementia mean that its prevention should be a priority for all those at risk as well as policymakers and clinicians.The global anti inflammatory drugs symbicort is caused by the anti-inflammatories symbicort entering human cells using angiotensin-converting enzyme 2 (ACE2) as a cell surface receptor.15,16 ACE2 is shed to the circulation and a higher plasma level of soluble ACE2 (sACE2) might reflect a higher cellular expression of ACE2 symbicort aerosol 160 4.5 mcg act.
In a research article âAngiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillationâ Lars Wallentin from the Uppsala Clinical Research Center in Sweden and colleagues explored the associations between sACE2 levels and clinical factors, cardiovascular biomarkers, and genetic variability.17 Plasma and DNA samples were obtained from â¼5000 elderly patients with atrial fibrillation from two international cohorts. The authors found that higher symbicort aerosol 160 4.5 mcg act levels of sACE2 were significantly associated with male sex, CVD, diabetes, and higher age. The sACE2 level was also most strongly associated with the levels of growth differentiation factor 15 (GDF-15), N-terminal probrain natriuretic peptide (NT-proBNP), and high-sensitive cardiac troponin T (hs-cTnT). When adjusting for these symbicort aerosol 160 4.5 mcg act biomarkers, only male sex remained associated with sACE2.
The authors found no significant genetic regulation of the sACE2 level (Figure 2).The authors conclude that the levels of GDF-15 and NT-proBNP, which are associated with both the sACE2 level and a higher risk for mortality and CVD, might contribute to better identification of risk for severe anti inflammatory drugs . The manuscript is accompanied by an Editorial by Dirk J. Van Veldhuisen from the University Hospital Groningen in the Netherlands, and colleagues who highlight that this study symbicort aerosol 160 4.5 mcg act is important and timely because it contributes to the growing body of research aimed at deciphering ACE2 pathophysiology and possible implications in anti inflammatory drugs care.18 Figure 2Summarizing concept on association between sACE2 and biological aging (from Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillation.
See pages 4037â4046).Figure 2Summarizing concept on association between sACE2 and biological aging (from symbicort aerosol 160 4.5 mcg act Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillation. See pages 4037â4046).In a State of the Art review entitled âHigh-sensitivity cardiac troponin assays for cardiovascular risk stratification in the general populationâ Dimitrios Farmakis from the University of Cyprus Medical School in Nicosia, Cyprus and colleagues note that cTnI and cTnT have long been the most successful cardiac-specific circulating biomarkers in cardiovascular medicine, having dramatically changed the diagnosis of acute myocardial infarction, while being independent predictors of outcome in several cardiac and non-cardiac conditions.19 The latest generation hs-cTn assays demonstrate both enhanced diagnostic performance and improved analytical performance, with the ability to symbicort aerosol 160 4.5 mcg act measure detectable concentrations in a substantial proportion of the asymptomatic and presumably healthy populations. Given this unique analytical feature, recent evidence suggests that hs-cTn can be used for the stratification of cardiovascular risk in the general population.
Hs-cTn predicts future cardiovascular events, is responsive to preventive pharmacological or lifestyle interventions, changes in parallel to risk modifications, and offers incremental risk prediction when added to well-established symbicort aerosol 160 4.5 mcg act prognosticators. They conclude that implementation of cardiovascular risk stratification and prevention strategies incorporating hs-cTn requires further investigation to define the optimal target populations, timing of measurement, and preventive interventions.Finally, in another State of the Art review entitled âEffects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomesâ Thomas Münzel from the Johannes Gutenberg Universität in Mainz, Germany, and colleagues point out that tobacco smoking is a leading cause of non-communicable disease globally and is a major risk factor for CVD and lung disease.20 Importantly, recent data form the World Health Organization (WHO) indicate that in the last two decades global tobacco use has significantly dropped, which was largely driven by decreased numbers of female smokers. Despite such advances, the use of e-cigarettes and waterpipes (shisha, hookah, and narghile) is an emerging trend, especially among younger generations. A growing body of evidence suggests that e-cigarettes are not a harm-free alternative to tobacco cigarettes and there is considerable debate as to symbicort aerosol 160 4.5 mcg act whether e-cigarettes are saving smokers or generating new addicts.
The authors provide an updated overview of the impact of tobacco/shisha smoking and e-cigarette vaping on endothelial function, a biomarker for early, subclinical, atherosclerosis from human and animal studies as well as of the emerging adverse effects on the proteome, transcriptome, epigenome, microbiome, and the circadian clock. The authors also discuss symbicort aerosol 160 4.5 mcg act the impact of the toxic constituents of these products on endothelial function and subsequent CVD. In addition, they provide an update on current recommendations, regulation, and advertising with focus on the USA and Europe.The editors hope that readers of this issue of the European Heart Journal will find it of interest. References1Grant PJ, symbicort aerosol 160 4.5 mcg act Cosentino F.
The 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. New features and the âTen Commandmentsâ of symbicort aerosol 160 4.5 mcg act the 2019 Guidelines are discussed by Professor Peter J. Grant and Professor Francesco Cosentino, the Task Force chairmen. Eur Heart J 2019;40:3215â3217.2Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O.
ESC Scientific Document Group symbicort aerosol 160 4.5 mcg act. 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Lipid modification to symbicort aerosol 160 4.5 mcg act reduce cardiovascular risk. Eur Heart J 2020;41:111â188.3Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S.
ESC Scientific Document symbicort aerosol 160 4.5 mcg act Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for symbicort aerosol 160 4.5 mcg act Cardiovascular Prevention &.
Rehabilitation (EACPR). Eur Heart symbicort aerosol 160 4.5 mcg act J 2016;37:2315â2381.4Dominguez-Rodriguez A, RodrÃguez S, Hernández-Vaquero D. Air pollution is intimately linked to global climate change. Change in Cardiovascular Disease Statistics symbicort aerosol 160 4.5 mcg act 2019.
Eur Heart J 2020;41:2601.5Yusuf S, Hawken S, Ãunpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L. INTERHEART Study symbicort aerosol 160 4.5 mcg act Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Caseâcontrol study.
Lancet 2004;364:937â952.6Münzel T, Miller MR, Sørensen M, symbicort aerosol 160 4.5 mcg act Lelieveld J, Daiber A, Rajagopalan S. Reduction of environmental pollutants for prevention of cardiovascular disease. Itâs time symbicort aerosol 160 4.5 mcg act to act. Eur Heart J 2020;41:3989â3997.7Ganz P, Heidecker B, Hveem K, Jonasson C, Kato S, Segal MR, Sterling DG, Williams SA.
Development and validation of symbicort aerosol 160 4.5 mcg act a protein-based risk score for cardiovascular outcomes among patients with stable coronary heart disease. JAMA 2016;315:2532â2541.8Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction symbicort aerosol 160 4.5 mcg act using targeted plasma proteomics in primary prevention. Eur Heart J 2020;41:3998â4007.9Ganz P, Deo R, Dubin RF.
Proteomics for personalized cardiovascular risk assessment. In pursuit of symbicort aerosol 160 4.5 mcg act the Holy Grail. Eur Heart J 2020;41:4008â4010.10Nanjo A, Evans H, Direk K, Hayward A, Story A, Banerjee A. Prevalence, incidence, and outcomes across cardiovascular diseases in homeless individuals using national linked electronic symbicort aerosol 160 4.5 mcg act health records.
Eur Heart J 2020;41:4011â4020.11Jayawardana S, Mossialos E. Lives cut short symbicort aerosol 160 4.5 mcg act. Socioeconomic inequities, homelessness, and cardiovascular disease. Eur Heart J 2020;41:4021â4022.12Lüscher TF.
The heart and symbicort aerosol 160 4.5 mcg act the brain. Cardiovascular risk factors, atrial fibrillation, and dementia. Eur Heart J 2019;40:2271â2275,13Rasmussen IJ, Rasmussen KL, Nordestgaard BG, Tybjærg-Hansen A, symbicort aerosol 160 4.5 mcg act Frikke-Schmidt R. Impact of cardiovascular risk factors and genetics on 10-year absolute risk of dementia.
Risk charts for symbicort aerosol 160 4.5 mcg act targeted prevention. Eur Heart J 2020;41:4024â4033.14Sommerlad A, Mukadam N. Evaluating risk of dementia in older symbicort aerosol 160 4.5 mcg act people. A pathway to personalized prevention?.
Eur Heart J 2020;41:4034â4036.15Xiong TY, Redwood S, Prendergast B, Chen M. anti-inflammatorieses and the cardiovascular symbicort aerosol 160 4.5 mcg act system. Acute and long-term implications. Eur Heart symbicort aerosol 160 4.5 mcg act J.
2020;41:1798â1800.16Pericà s JM, Hernandez-Meneses M, Sheahan TP, Quintana E, Ambrosioni J, Sandoval E, Falces C, Marcos MA, Tuset M, Vilella A, Moreno A, Miro JM. Hospital ClÃnic Cardiovascular s symbicort aerosol 160 4.5 mcg act Study Group. anti inflammatory drugs. From epidemiology to treatment.
Eur Heart J symbicort aerosol 160 4.5 mcg act. 2020;41:2092â2112.17Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in symbicort aerosol 160 4.5 mcg act two large cohorts of patients with atrial fibrillation. Eur Heart J 2020;41:4037â4046.18Sama IE, Voors AA, van Veldhuisen DJ.
New symbicort aerosol 160 4.5 mcg act data on soluble ACE2 in patients with atrial fibrillation reveal potential value for treatment of patients with anti inflammatory drugs and cardiovascular disease. Eur Heart J 2020;41:4047â4049.19Farmakis D, Mueller C, Apple FS. High-sensitivity cardiac troponin assays for cardiovascular risk stratification in the general population symbicort aerosol 160 4.5 mcg act. Eur Heart J 2020;41:4050.20Münzel T, Hahad O, Kuntic M, Keaney JF, Deanfield JE, Daiber A.
Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. Eur Heart J 2020;41:4057 symbicort aerosol 160 4.5 mcg act. Published on behalf of the European Society of Cardiology. All rights symbicort aerosol 160 4.5 mcg act reserved.
© The Author(s) 2020. For permissions, symbicort aerosol 160 4.5 mcg act please email. Journals.permissions@oup.com.Abstract IntroductionCardiovascular disease (CVD) represents the result of underlying genetic predisposition and lifetime exposure to multiple environmental factors. The past century has seen a revolution in our understanding of the importance symbicort aerosol 160 4.5 mcg act of modifiable risk factors such as diet, exercise, and smoking.
Exposure to environmental pollutants, be it in the air, water, or physical environment, is increasingly recognized as a silent, yet important determinant of CVD.1 The quote âgenetics loads the gun but the environment pulls the triggerâ, put forward by G.A. Bray and F. Collins, exemplifies the complex relationship symbicort aerosol 160 4.5 mcg act between human disease and the environment. The cardiovascular system is highly vulnerable to a variety of environmental insults, including tobacco smoke, solvents, pesticides, and other inhaled or ingested pollutants, as well as extremes in noise and temperature.
While our understanding of multiple environmental factors continues to evolve, it is estimated that environmental air pollution and noise pollution alone may contribute to a substantial burden attributable to environmental factors symbicort aerosol 160 4.5 mcg act as we currently understand them. It is important to note that noise and air pollution can have many of the same sources such as heavy industry, road and aircraft vehicles. In a recent in-depth report, the European Commission acknowledged that the symbicort aerosol 160 4.5 mcg act societal costs for the combination noise and air pollution are nearly 1 trillion Euros, while the costs for alcohol and smoking are considerably less (50â120 and 540 billion Euro, respectively, see https://ec.europa.eu/environment/integration/research/newsalert/pdf/air_noise_pollution_socioeconomic_status_links_IR13_en.pdf). The World Health Organization (WHO) calculates that 12.6 million premature deaths per year are attributable to unhealthy environments, 8.2 million of which are due to non-communicable disease, with CVD (including stroke) being the largest contributor, accounting for nearly 5 million of these deaths.2 Among all environmental pollutants, poor air quality is the most important risk factor, and ambient air pollution due to particulate matter <2.5âµm (PM2.5) exposure ranks 5th among all global risk factors in 2015, leading to 4.2 million deaths annually as estimated by the Global Burden of Disease study.3 Nine out of 10 people worldwide are exposed to ambient air pollutant levels above WHO guidelines (>10âµg/m).3,4 Using a novel exposure-response hazard function (global estimate of exposure mortality model) to estimate global mortality attributable to air pollution, Burnett et al.5 and Lelieveld et al.6 found that around 9 million global premature deaths (790 000 excess deaths in Europe alone) were attributable to air pollution,7 numbers that are well comparable to that of smoking.6 These figures are substantially higher than those estimated by the WHO and Global Burden of Disease study.2,3Ambient noise is the other omnipresent exposure with emerging data suggesting a large attributable burden of disability to this factor in many urban environments.
In Western Europe, it is estimated that around 1.6 million healthy life years are lost every year due to noise. It is estimated that a large part symbicort aerosol 160 4.5 mcg act of the European population is exposed to noise originating from road traffic at levels exceeding 55 decibels [dB(A), A-weighted decibel scale adapted to the human hearing frequencies]. 20% exposed to levels exceeding 65âdB(A) during the daytime. And 30% of the population is exposed to levels symbicort aerosol 160 4.5 mcg act exceeding 55âdB(A) (see https://www.eea.europa.eu/publications/environmental-noise-in-europe).
In this review, we will focus on the cardiovascular effects of ambient air pollution and noise pollution as prototypical environmental factors that provide important lessons to facilitate understanding of the outsize effects of the environment on susceptibility to CVD. The pathophysiology, epidemiology, mitigation measures, and future challenges for these two common yet pervasive environmental factors are discussed in detail.In many parts of the world, a symbicort aerosol 160 4.5 mcg act substantial portion of the urban population is exposed to road traffic noise at levels exceeding 55âdB(A).8 In cities in Asia, the proportion of the population reaching Lden levels (dayâeveningânight level, i.e. The average sound pressure level measured over a 24âh period with adjustment for more detrimental health effects of nocturnal noise) of 60â64âdB is very high.9 In contrast to the relatively straightforward classification of noise, air pollution is intrinsically complex and defy easy classification. From a regulatory perspective, âcriteriaâ air symbicort aerosol 160 4.5 mcg act pollutants allow health-based and/or environmentally based guidelines for setting permissible levels.10 These include carbon monoxide, lead, nitrogen oxides, ground-level ozone, particle pollution (often referred to as PM), and sulphur oxides.
Particulate matter is categorized based on its aerodynamic diameter. ¤10âμm [thoracic particles (PM10)], â¤2.5âμm [fine particles (PM2.5)], â¤0.1âμm [ultrafine particles (UFP)], and between 2.5 and 10âμm [coarse particles (PM2.5â10)]. Although âcriteriaâ pollutants are regulated individually, it is anticipated that the effects of air pollution are driven by the complex interaction of particulate and gaseous components in mixtures and that symbicort aerosol 160 4.5 mcg act smaller particles (e.g. UFP) are more detrimental then larger ones.There is substantial spatial and temporal variation of both noise and air pollution.
Traffic-related pollutants symbicort aerosol 160 4.5 mcg act and noise often peaking during the late morning and evening rush hours. Gradients for both noise and air pollutants are also dependent upon meteorological conditions, including diurnal changes in vertical mixing height, wind speed, and temperature. In the case of noise, the gradients are substantial symbicort aerosol 160 4.5 mcg act as the intensity of noise decreases exponentially with the distance from its source. The gradients for air pollution from their source may also differ depending upon the pollutant.
Traffic factors, such as the speed, traffic load, etc., may also differentially affect noise and traffic-related air pollution symbicort aerosol 160 4.5 mcg act. During traffic congestion, when traffic is at standstill or at lower engine speeds, noise levels may be lower, but emissions may be dramatically higher, contributing to marked surges in traffic-related air pollutants. In contrast, when traffic is moving well, noise levels may be higher, but emissions may be lower. Environmental factors such as road conditions, noise barriers, and surrounding buildings are well known to influence traffic noise but may not influence air pollution substantially.The highly associated nature of traffic noise and air pollution makes it challenging to isolate their independent effects on cardiovascular events symbicort aerosol 160 4.5 mcg act in epidemiological studies.
A few studies have attempted to assess the independent contribution of noise from air pollution and vice versa. The results are, however, somewhat variable, with some studies demonstrating an independent effect of noise and/or air pollution on cardiovascular morbidity and mortality, while others find marked attenuation of effects after adjusting for the other symbicort aerosol 160 4.5 mcg act. Whether noise and air pollution have differing, additive, synergistic, and/or confounding effects upon cardiovascular health is still incompletely understood. Also of great importance in all air pollution and noise exposure studies is the co-linearity of these risk symbicort aerosol 160 4.5 mcg act factors to other confounders (e.g.
Lower socio-economic status, psychosocial stressors, other poorly understood environmental variables and adverse lifestyle factors) that often go hand-in-hand with pollutants. Pathophysiology and epidemiology of noise and cardiovascular disease EpidemiologyDuring the last decade, a number of epidemiological studies have investigated effects of transportation noise on risk for CVD. In 2018, a systematic review by WHO found that there was substantial evidence to conclude that road traffic noise increases the risk for ischaemic heart disease, with an 8% higher risk per 10âdB higher noise.11 For stroke, the evidence was ranked as moderate, with only one study on incidence and four on mortality.11 Subsequently, large population-based studies from Frankfurt, London, and Switzerland found road traffic noise to increase stroke incidence and/or mortality, especially ischaemic strokes,12â14 whereas smaller cohort studies indicated no association.15 Recently, road traffic noise has been found to increase the risk for other major CVD not evaluated by WHO, most importantly heart failure and atrial fibrillation.14,16 Aircraft noise has also been associated with higher CVD incidence and mortality,14,17 but due to a limited number of studies, the evidence is still rated low to moderate.18Epidemiological studies have linked transportation noise with a number of major cardiovascular risk factors, most consistently obesity and diabetes.19,20 Also, many studies investigated effects of noise on hypertension, and although a meta-analysis of 26 studies found that road traffic noise was associated with higher prevalence of hypertension,11 studies on incidence are still few and inconsistent.Ambient air pollution and traffic noise, especially from roads, are correlated and suspected symbicort aerosol 160 4.5 mcg act of being associated with the same CVD, and therefore mutual adjustment is highly important. Most recent studies on noise and CVD adjust for air pollution and generally the results are found to be robust to the adjustment, suggesting that transportation noise is indeed an independent risk factor for CVD.21Another noise source investigated in relation to CVD risk is occupational noise.
An exposure symbicort aerosol 160 4.5 mcg act mainly occurring during daytime. Most existing studies are cross-sectional, and results from a few prospective studies providing conflicting evidence, with some studies indicating an association with CVD,22 whereas others finding no association,23 stressing the need for more well-designed prospective studies. PathophysiologyAccording to the noise stress reaction model introduced by Babisch,24non-auditory health effects of noise have been demonstrated to activate a so-called âindirect pathwayâ, symbicort aerosol 160 4.5 mcg act which in turn represents the cognitive perception of the sound, and its subsequent cortical activation is related to emotional responses such as annoyance and anger (reviewed in Ref. 25) This stress reaction chain can initiate physiological stress responses, involving the hypothalamus, the limbic system, and the autonomic nervous system with activation of the hypothalamusâpituitaryâadrenal (HPA) axis and the sympatheticâadrenalâmedulla axis, and is associated with an increase in heart rate and in levels of stress hormones (cortisol, adrenalin, and noradrenaline) enhanced platelet reactivity, vascular inflammation, and oxidative stress (see Figure 1).
While the conscious experience with noise might be the primary symbicort aerosol 160 4.5 mcg act source of stress reactions during daytime (for transportation and occupational noise), the sub-conscious biological response during night-time in sleeping subjects, at much lower transportation noise levels, is thought to play an important role in pathophysiology, particularly through disruption of sleepâwake cycle, diurnal variation, and perturbation of time periods critical for physiological and mental restoration. Recent human data provided a molecular proof of the important pathophysiological role of this âindirect pathwayâ by identifying amygdalar activation (using 18F-FDGPET/CT imaging) by transportation noise in 498 subjects, and its association with arterial inflammation and major adverse cardiovascular events.27 These data are indeed consistent with animal experiments demonstrating an increased release of stress hormones (catecholamines and cortisol), higher blood pressure, endothelial dysfunction,28 neuroinflammation, diminished neuronal nitric oxide synthase (nNOS) expression as well as cerebral oxidative stress in aircraft noise-exposed mice.29 These changes were substantially more pronounced when noise exposure was applied during the sleep phase (reflecting night-time noise exposure) and was mostly prevented in mice with genetic deletion or pharmacological inhibition of the phagocytic NADPH oxidase (NOX-2).29 These studies also revealed substantial changes in the gene regulatory network by noise exposure, especially within inflammatory, antioxidant defence, and circadian clock pathways (Figure 1).28,29 The conclusions from these experiments are supportive of a role for shortened sleep duration and sleep fragmentation in cerebrovascular oxidative stress and endothelial dysfunction. Figure 1The key mechanisms of the adverse health effects of traffic noise exposure. Environmental noise symbicort aerosol 160 4.5 mcg act exposure causes mental stress responses, a neuroinflammatory phenotype, and cognitive decline.
This may lead to manifest psychological disorders and mental diseases or, via stress hormone release and induction of potent vasoconstrictors, to vascular dysfunction and damage. All of symbicort aerosol 160 4.5 mcg act these mechanisms initiate cardio-metabolic risk factors that lead to manifest end organ damage. Of note, chronic cardio-metabolic diseases often are associated with psychological diseases and vice versa.26 ⢠ACTH, adrenocorticotropic hormone. ADH, antidiuretic hormone (vasopressin) symbicort aerosol 160 4.5 mcg act.
ATII, angiotensin II. CRH, corticotropin-releasing hormone symbicort aerosol 160 4.5 mcg act. ENOS, endothelial nitric oxide synthase. ET-1, endothelin-1;NO, nitric oxide.
NOX-2, phagocytic symbicort aerosol 160 4.5 mcg act NADPH oxidase (catalytic subunit).Figure 1The key mechanisms of the adverse health effects of traffic noise exposure. Environmental noise exposure causes mental stress responses, a neuroinflammatory phenotype, and cognitive decline. This may lead to manifest psychological disorders and mental diseases or, via stress hormone release and induction symbicort aerosol 160 4.5 mcg act of potent vasoconstrictors, to vascular dysfunction and damage. All of these mechanisms initiate cardio-metabolic risk factors that lead to manifest end organ damage.
Of note, chronic cardio-metabolic diseases often are associated symbicort aerosol 160 4.5 mcg act with psychological diseases and vice versa.26 ⢠ACTH, adrenocorticotropic hormone. ADH, antidiuretic hormone (vasopressin). ATII, angiotensin II. CRH, corticotropin-releasing hormone symbicort aerosol 160 4.5 mcg act.
ENOS, endothelial nitric oxide synthase. ET-1, endothelin-1;NO, symbicort aerosol 160 4.5 mcg act nitric oxide. NOX-2, phagocytic NADPH oxidase (catalytic subunit).Likewise, we observed a significant degree of endothelial dysfunction, an increase in stress hormone release, blood pressure and a decrease in sleep quality in healthy subjects and patients with established coronary artery disease, in response to night-time aircraft noise (reviewed in Ref.25) Importantly, endothelial dysfunction was corrected by the antioxidant vitamin C indicating increased vascular oxidative stress in response to night-time aircraft noise exposure. The important role of oxidative stress and inflammation for noise-induced cardiovascular complications was also supported by changes of the plasma proteome, centred on redox, pro-thrombotic and proinflammatory pathways, in subjects exposed to train noise for one night [mean SPL 54âdB(A)].30 Pathophysiology and epidemiology of air pollution and cardiovascular diseaseSince the publication of an American Heart Association Scientific Statement,31 there has been a consistent stream of epidemiological symbicort aerosol 160 4.5 mcg act and mechanistic evidence linking PM2.5, the most frequently implicated air pollution component with CVD.5,6 Mounting evidence suggests that health risks attributable to PM2.5 persist even at low levels, below WHO air quality guidelines and European standards (annual levels <10 and <25âµg/m3, respectively).
Updated exposure-response dose curves suggest a robust supralinear concentration-response-curve for PM and CVD with no apparent safe threshold level.32 EpidemiologyCurrent estimates suggest air pollution is associated with around 9 million premature deaths, worldwide annually with â¼40â60% of mortality attributed to cardiovascular causes.5,33Short-term exposure (over hours or days) is associated with increased risk for myocardial infarction, stroke, heart failure, arrhythmia, and sudden death by about 1â2% per 10âµg/m3. Longer-term exposure over symbicort aerosol 160 4.5 mcg act months or years, amplifies these risk associations, to 5â10% per 10âµg/m3. Living in regions with poor air quality potentiates the atherosclerotic process and promotes the development of several chronic cardio-metabolic conditions (e.g. Diabetes, hypertension).Although the strength of the association for criteria air pollutants is strongest for PM2.5, there are data linking other pollutants such as nitrogen oxides (e.g.
NO2) and less consistently symbicort aerosol 160 4.5 mcg act ozone (O3) with cardiovascular events.32 Pollutants from traffic and combustion sources are of high concern (due to high levels of ultrafine PM, toxicity of constituents, and penetration of pollutants systemically) although precise burden estimates have yet to be established for this source. Coarse PM10 air pollution from anthropogenic sources has been associated with cardiovascular disease although sources such as agricultural emissions and crustal material are less well studied.Given the continuing links between PM2.5 and adverse cardiovascular events, even at levels substantially below 10âµg/m3, there is a need for a realistic lower limit that may strike the balance between what is reasonably possible and eliminating anthropogenic sources. It is important to symbicort aerosol 160 4.5 mcg act keep in mind that complete elimination of all PM2.5 may not possible given that some PM2.5 is natural. Calculations by Lelieveld et al.33 of a complete phase-out of fossil fuel-related emissions (needed to achieve the 2°C climate change goal under the Paris Agreement) demonstrated a reduction in excess mortality rate of 3.61 million per year worldwide.
The increase in mean life expectancy in Europe would be around 1.2âyears indicating a tremendous symbicort aerosol 160 4.5 mcg act health co-benefit from the phase-out of carbon dioxide emissions. PathophysiologyMechanistic studies, using controlled exposure studies in humans and experimental models support a causal relationship between PM and CVD. Acute exposure to air pollutants induces rapid changes that include vasoconstriction, endothelial dysfunction, arterial stiffening, arrhythmia, exacerbation of cardiac ischaemia, increased blood coagulability, and decreased fibrinolytic capacity. Additionally, long-term exposure to PM accelerates the growth and vulnerability of atherosclerotic plaques.34 A broad range of mechanisms accounts for pathophysiology at an organ and cellular level, with inflammation and oxidative stress playing key roles.25 Additionally, several convincing pathways can account for the link between inhalation of pollutants and the cardiovascular system, including passage of inflammatory (and other) mediators into the circulation, direct passage of particles (or their constituents) into circulation, imbalance of autonomic nervous system activity, and changes symbicort aerosol 160 4.5 mcg act to central control of endocrine systems.
The contribution of individual pathways will depend on type of pollutant, the exposure (dose and duration), specific cardiovascular endpoints, and the health status of individual. Finally, the cardiovascular effects of pollutants occur in both healthy individuals and those with pre-existing cardiorespiratory disease, suggesting a potential contributory role on the induction, progression, and exacerbation of CVD.32,34 Mitigation symbicort aerosol 160 4.5 mcg act strategies Noise mitigationIn 2020, the European Environment Agency concluded that more than 20% of the EU population live with road traffic noise levels that are harmful to health and that this proportion is likely to increase in the future (see https://www.eea.europa.eu/publications/environmental-noise-in-europe [last accessed 17/09/2020]). European Environment Agency also estimated that in EU, 22 million live with high railway noise and 4 million with high aircraft noise.The authorities can use different strategies to reduce levels of traffic noise (Table 1). For road traffic, the sound generated by the contact between the tires and the pavement is the dominant noise source, at speeds above 35âkm/h for cars symbicort aerosol 160 4.5 mcg act and above 60âkm/h for trucks.
Therefore, changing to electric cars will result in only minor reductions in road traffic noise. Generally applied strategies for reducing road traffic noise include noise barriers in densely populated symbicort aerosol 160 4.5 mcg act areas, applying quiet road surfaces, and reducing speed, especially during night-time. Furthermore, there is a great potential in developing and using low-noise tires. As many of these mitigation methods result in only relatively small changes in noise (Table 1), a combination of different methods is important in highly exposed areas.
For aircraft noise, mitigation strategies include to minimizing overlapping of air traffic routes and housing zones, introduction of night bans, and implementation of continuous descent arrivals, which require the aircraft to approach on steeper descents symbicort aerosol 160 4.5 mcg act with lower, less variable throttle settings. For railway noise, replacing cast-iron block breaks with composite material, grinding of railway tracks and night bans, are among the preferred strategies for reducing noise. Lastly, installing sound-reducing windows and/or orientation of the bedroom towards the quiet side of the residence can reduce noise exposure symbicort aerosol 160 4.5 mcg act. Table 1Mitigation methods resulting in reduction in road traffic noise Change in noise.
Perceived change symbicort aerosol 160 4.5 mcg act. Methods for noise reduction. 1 dB A very small change symbicort aerosol 160 4.5 mcg act. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change.
Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove symbicort aerosol 160 4.5 mcg act 65% of traffic 10 dB A large change. Sounds like a halving of the sound. Build high noise barriers Remove 90% of symbicort aerosol 160 4.5 mcg act the traffic Sound-reducing windows Change in noise.
Perceived change. Methods for symbicort aerosol 160 4.5 mcg act noise reduction. 1 dB A very small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change.
Reduce speed by 30 km/h symbicort aerosol 160 4.5 mcg act Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A large change. Sounds like a halving of the symbicort aerosol 160 4.5 mcg act sound. Build high noise barriers Remove 90% of the traffic Sound-reducing windows Table 1Mitigation methods resulting in reduction in road traffic noise Change in noise.
Perceived change symbicort aerosol 160 4.5 mcg act. Methods for noise reduction. 1 dB A very symbicort aerosol 160 4.5 mcg act small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change.
Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A large change symbicort aerosol 160 4.5 mcg act. Sounds like a halving of the sound. Build high noise barriers Remove 90% of symbicort aerosol 160 4.5 mcg act the traffic Sound-reducing windows Change in noise.
Perceived change. Methods for noise reduction symbicort aerosol 160 4.5 mcg act. 1 dB A very small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 symbicort aerosol 160 4.5 mcg act dB An audible, but small change.
Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A large change. Sounds like a symbicort aerosol 160 4.5 mcg act halving of the sound. Build high noise barriers Remove 90% of the traffic Sound-reducing windows Air pollution mitigationAlthough it is widely recognized that legislation, policies, regulation, and technology, coupled with enforcement, are critical to reduction of air pollution levels, the political momentum required to accomplish this globally is currently limited.
Thus, personal measures to mitigate risk take on a much symbicort aerosol 160 4.5 mcg act greater importance. The current experience and lessons learned with personal protective equipment and mitigation in reducing exposure to SARS-CoV2 are highly reminiscent of their use in combating air pollution, albeit the protection provided varies depending on the pollutant.35 Mitigation measures must be affordable and broadly applicable to the population, and the level of protection provided should match the risk of population that is being exposed (Figure 2). The latter would necessitate an understanding of the symbicort aerosol 160 4.5 mcg act health risk of the patient/community and degree of exposure. The need and urgency plus intensity of any recommended intervention also need to be weighed against their potential benefits vs.
Risks for each individual (e.g. Wasted effort, resources, unnecessary concern, or possible complacency of symbicort aerosol 160 4.5 mcg act the user). Although no intervention to reduce air pollution exposure has as yet been shown to reduce cardiovascular events, the consistent link between increased levels of PM2.5 and cardiovascular events, evidence for measures in lowering PM2.5 levels, and the impact of several mitigation strategies in improving surrogate markers are highly suggestive that interventions could be correspondingly impactful in reducing cardiovascular events. Figure 2Mitigation measures to reduce air pollution exposure.Figure 2Mitigation measures to reduce air pollution exposure.Current approaches to mitigate air pollution and symbicort aerosol 160 4.5 mcg act their impact have been previously reviewed and can be broadly classified into.
(i) Active personal exposure mitigation with home air cleaning and personal equipment (Table 2). (ii) Modification of human behaviour to reduce passive symbicort aerosol 160 4.5 mcg act exposures. (iii) Pharmacologic approaches.32 Studies on N95 respirator under ambient PM2.5 exposure conditions at both high and low levels of exposures over a few hours have shown to reduce systolic blood pressure and improve heart rate variability.32,36 In the only trial comparing exposure mitigation to both noise and air pollution, individual reduction of air pollution or noise with a respirator or noise-cancelling headphones, respectively, did not alter blood pressure. Heart rate variability indices were, however, variably symbicort aerosol 160 4.5 mcg act improved with either intervention.37 Face masks and procedural masks (e.g.
Surgical masks) are widely available but are not effective in filtering PM2.5, especially if poorly fitting or worn during high activity,38 and therefore cannot be recommended for widespread usage if N95 respirators are available. Closing car windows, air-conditioning, and cabin air filters represent approaches that could be important in those who are susceptible, but only in those spending large amounts of time in transportation microenvironments. Behavioural strategies such as air pollution avoidance by changing travel routes, staying indoors/closing windows, and modification of activity can help limit air pollution exposure, but unintended consequences in some instances symbicort aerosol 160 4.5 mcg act have the potential of offsetting benefit. An example is closing windows to limit outdoor exposure but increasing the hazard for indoor air pollutants or limiting outdoor recreation/exercise to mitigate ambient exposures.
The latter scenario of limiting outdoor exposure brings up some very practical questions about the risk/benefit of loss of cardiovascular benefits of exercise symbicort aerosol 160 4.5 mcg act vs. Potential gain from benefits secondary to air pollution mitigation. Health impact modelling and epidemiologic studies have demonstrated that the benefits of aerobic exercise nearly always exceed the risk of air pollution symbicort aerosol 160 4.5 mcg act exposure across a range of concentrations, and for long durations of exercise for normal individuals (>75âmin). Based on current evidence, guiding healthy people to avoid outdoor activity in areas with high PM2.5 pollution has the potential to produce greater harm than benefit, given the low absolute risk for cardiovascular or respiratory events.
On the other hand, advising patients with pre-established CVD to continue to remain >400âm away from major symbicort aerosol 160 4.5 mcg act roadways to avoid exposure to traffic pollutants is a reasonable measure, despite the current lack of strong evidentiary support. Table 2Personal active mitigation methods to reduce air pollution exposure Type of intervention. Efficacy in reducing exposure. Considerations for symbicort aerosol 160 4.5 mcg act use.
Evidence in reducing surrogate outcomes. Personal air purifying respirators (reducing symbicort aerosol 160 4.5 mcg act solid but not gaseous air pollutants). ÂN95 respirators Highly effective in reducing PM2.5. Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency are key symbicort aerosol 160 4.5 mcg act determinants of efficacy.
A valve or microventilator fan may reduce humidity and enhance comfort. Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks Not uniformly effective symbicort aerosol 160 4.5 mcg act in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters.
Electrostatic PACs additionally ionize particles Designed to clean air in a small symbicort aerosol 160 4.5 mcg act area. Effective in reducing indoor particles but duration of use and volume of room, key determinants of efficacy. Efficacy related to clean air delivery rate normalized by room volume, which must be competitive with ventilation symbicort aerosol 160 4.5 mcg act and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure.
Effective in reducing concentrations as long as symbicort aerosol 160 4.5 mcg act filters replaced regularly. Efficacy is variable with building and operational factors (i.e. Open windows) No data currently available Type of intervention. Efficacy in symbicort aerosol 160 4.5 mcg act reducing exposure.
Considerations for use. Evidence in reducing surrogate outcomes symbicort aerosol 160 4.5 mcg act. Personal air purifying respirators (reducing solid but not gaseous air pollutants). ÂN95 respirators Highly effective in reducing PM2.5 symbicort aerosol 160 4.5 mcg act.
Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency are key determinants of efficacy. A valve or microventilator fan may symbicort aerosol 160 4.5 mcg act reduce humidity and enhance comfort. Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy.
Not recommended owing to variability in reducing exposure to particles Portable symbicort aerosol 160 4.5 mcg act air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize particles Designed to clean air in a small area. Effective in reducing indoor particles but duration symbicort aerosol 160 4.5 mcg act of use and volume of room, key determinants of efficacy. Efficacy related to clean air delivery rate normalized by room volume, which must be competitive with ventilation and deposition (loss) rates.
Electrostatic PACs may result symbicort aerosol 160 4.5 mcg act in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure. Effective in reducing concentrations as long as filters replaced regularly. Efficacy is variable with building and operational factors (i.e. Open windows) No data currently available Table 2Personal active symbicort aerosol 160 4.5 mcg act mitigation methods to reduce air pollution exposure Type of intervention.
Efficacy in reducing exposure. Considerations for symbicort aerosol 160 4.5 mcg act use. Evidence in reducing surrogate outcomes. Personal air symbicort aerosol 160 4.5 mcg act purifying respirators (reducing solid but not gaseous air pollutants).
ÂN95 respirators Highly effective in reducing PM2.5. Removes >95% inhaled particles at 0.3 µm in size Fit and symbicort aerosol 160 4.5 mcg act use frequency are key determinants of efficacy. A valve or microventilator fan may reduce humidity and enhance comfort. Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices.
ÂSurgical and cloth masks Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these symbicort aerosol 160 4.5 mcg act may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize particles Designed to clean air in a small area symbicort aerosol 160 4.5 mcg act. Effective in reducing indoor particles but duration of use and volume of room, key determinants of efficacy.
Efficacy related to clean air symbicort aerosol 160 4.5 mcg act delivery rate normalized by room volume, which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure. Effective in reducing concentrations as long as filters replaced regularly. Efficacy is variable with building and symbicort aerosol 160 4.5 mcg act operational factors (i.e.
Open windows) No data currently available Type of intervention. Efficacy in symbicort aerosol 160 4.5 mcg act reducing exposure. Considerations for use. Evidence in symbicort aerosol 160 4.5 mcg act reducing surrogate outcomes.
Personal air purifying respirators (reducing solid but not gaseous air pollutants). ÂN95 respirators Highly effective symbicort aerosol 160 4.5 mcg act in reducing PM2.5. Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency are key determinants of efficacy. A valve or microventilator fan may reduce humidity and enhance comfort.
Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability symbicort aerosol 160 4.5 mcg act indices. ÂSurgical and cloth masks Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air symbicort aerosol 160 4.5 mcg act cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize particles Designed to clean air in a small area.
Effective in reducing indoor particles but duration symbicort aerosol 160 4.5 mcg act of use and volume of room, key determinants of efficacy. Efficacy related to clean air delivery rate normalized by room volume, which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that symbicort aerosol 160 4.5 mcg act reduce exposure. Effective in reducing concentrations as long as filters replaced regularly.
Efficacy is variable with building and operational factors (i.e. Open windows) No data currently available Although a variety of over the counter drugs and medications have been shown to mitigate association between air pollution and surrogates, almost none can be recommended to protect against symbicort aerosol 160 4.5 mcg act air pollution mediated adverse health effects at this time. However, the use of medications for primary and secondary prevention of CHD should be encouraged if indicated for other reasons. Housing and urban design to improve cardiovascular healthTwo-third of the European population live in urban areas and this symbicort aerosol 160 4.5 mcg act number continues to grow.
A recent Statement on Air Quality Policy has discussed aspects in the built environment that may be targeted in order to reduce exposures to PM2.5 (in press 2020). Briefly, built environment features may directly or indirectly modify adverse cardiovascular effects of air pollution through the indoor living environment, green symbicort aerosol 160 4.5 mcg act spaces, roads, utilities, and transportation infrastructure. The design of communities has the potential of impacting exposures, by affecting the continuum of human existence across indoor living, commuting, working, and recreation (Figure 3). The layout of roads, sidewalks, green spaces, and the availability of cheap public transportation can affect travel behaviour and can help alleviate air quality.39 Communities with proximity and compactness have been associated with higher life expectancy, improved air quality, and health.40,41 Green environments can improve air quality, encourage physical activity, and promote social interactions, ultimately improving cardiovascular health.
Indeed, there symbicort aerosol 160 4.5 mcg act is evidence to support a protective association of green spaces on PM-associated CVD.42,43All-cause and ischaemic heart disease mortality related to income deprivation has been shown to be lower in populations who live in the greenest areas, vs. Those who have less exposure to green space.44 Recently, Giles-Corti identified eight integrated regional and local interventions that, when combined, encourage walking, cycling and public transport use, while reducing private motor vehicle use.45 These eight interventions are directed to reduce traffic exposure, to reduce air pollution and noise, and to reduce the important public health issue loneliness and social isolation, to improve the safety from crime, to reduce physical inactivity and prolonged sitting, and to prevent the consumption of unhealthy diets.45 Figure 3Urban design considerations to reduce exposure to noise and air pollution.Figure 3Urban design considerations to reduce exposure to noise and air pollution. Take home figureUpper left panel reproduced from Münzel et al.46 with permission.Take home figureUpper left panel symbicort aerosol 160 4.5 mcg act reproduced from Münzel et al.46 with permission. Future perspectives.
Opportunities and challenges over the next decadeEfforts to mitigate air pollution and noise symbicort aerosol 160 4.5 mcg act are endeavours that involve complex economic and geopolitical considerations. Measures such as transportation reform, shift to zero-emission fuels, urban landscape reform, and ecologically sound lifestyle changes may help simultaneously alleviate air/noise pollution while accomplishing climate change goals. However, reducing air pollution and noise may have short-term challenges due to economic incentives that are substantially misaligned with health and environmental priorities and thus symbicort aerosol 160 4.5 mcg act opportunities to understand the importance of these factors in human health will sadly continue. An important avenue of investigation is convergent studies that look at the broad and collective impact and burden of air and noise pollution as archetypal environmental risk factors.
The questions that need to be addressed are many and include the magnitude and time course of response of co-exposure, interactive effects of environmental factors on surrogate measures, duration of effect/time course of reversal, impact on circadian rhythm, and finally the effect of reversal as well as prevention and lifestyle approaches that may help mitigate risk (e.g. Diet, stress, and exercise).The rapid development of personalized technologies that provide multiple measures of health in fine temporal detail in conjunction with data on environmental exposure provide an unprecedented opportunity for research and may allow an extraordinary understanding of the interactions between environmental and non-environmental risk factors over long durations symbicort aerosol 160 4.5 mcg act. Together with developments in next-generation sequencing technologies, and opportunities in big data, assimilative studies of this nature may finally provide a granular view of the environmentalâgenetic interactions leading to the development of CVD. However, the extent of these advances symbicort aerosol 160 4.5 mcg act may be tempered by the need to manage subject burden and costs, and imprecise data on many environmental variables.
Increased awareness of the societal burden posed by environmental risk factors and acknowledgement in traditional risk factor guidelines may pressurize politicians to intensify the efforts required for effective legislation.The cardiovascular community has a responsibility to help promulgate the impact of, not only health lifestyle and diet, but also over the outsize impact of air and noise pollution on cardiovascular health. Individuals can apply political pressure through democratic means and lobbying to enact changes at regional and symbicort aerosol 160 4.5 mcg act national levels that lead to reductions in noise/air pollution exposure. Patient organization can provide a strong voice in the call for action at governmental level. Importantly, air pollution was mentioned in the published guidelines for cardiovascular prevention, but the recommendations to symbicort aerosol 160 4.5 mcg act reduce pollution were completely insufficient,47 while prevention measures with respect to traffic noise were completely lacking.
Noise and air pollution represent significant cardiovascular risk factors, it is important that these factors are included into the ESC guidelines, and others, for myocardial infarction, arterial hypertension, and heart failure. AcknowledgementsWe are indebted to the expert graphical assistance of Margot Neuser. FundingA.D. And T.M.
Were supported by vascular biology research grants from the Boehringer Ingelheim Foundation for the collaborative research group âNovel and neglected cardiovascular risk factors. Molecular mechanisms and therapeuticsâ with continuous research support from Foundation Heart of Mainz. T.M. Is PI of the DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany.
M.R.M. Is supported by the British Heart Foundation (CH/09/002). S.R. Was supported in part by the National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH) under Award Numbers U01ES026721 and 5R01ES019616-07 and 1R01ES026291.Conflict of interest.
None declared. References1Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu NN, Balde AB, Bertollini R, Bose-O'Reilly S, Boufford JI, Breysse PN, Chiles T, Mahidol C, Coll-Seck AM, Cropper ML, Fobil J, Fuster V, Greenstone M, Haines A, Hanrahan D, Hunter D, Khare M, Krupnick A, Lanphear B, Lohani B, Martin K, Mathiasen KV, McTeer MA, Murray CJL, Ndahimananjara JD, Perera F, Potocnik J, Preker AS, Ramesh J, Rockstrom J, Salinas C, Samson LD, Sandilya K, Sly PD, Smith KR, Steiner A, Stewart RB, Suk WA, van Schayck OCP, Yadama GN, Yumkella K, Zhong M. The Lancet Commission on pollution and health. Lancet 2018;391:462â512.2Aronow WS.
Drug treatment of elderly patients with acute myocardial infarction. Practical recommendations. Drugs Aging 2001;18:807â818.3Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, Balakrishnan K, Brunekreef B, Dandona L, Dandona R, Feigin V, Freedman G, Hubbell B, Jobling A, Kan H, Knibbs L, Liu Y, Martin R, Morawska L, Pope CA3rd, Shin H, Straif K, Shaddick G, Thomas M, van Dingenen R, van Donkelaar A, Vos T, Murray CJL, Forouzanfar MH. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution.
An analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017;389:1907â1918.4Hirose R, Okumura H, Yoshimatsu A, Irie J, Onoda Y, Nomoto Y, Takai H, Ohno T, Ichimura M. KF31327, a new potent and selective inhibitor of cyclic nucleotide phosphodiesterase 5. Eur J Pharmacol 2001;431:17â24.5Burnett R, Chen H, Szyszkowicz M, Fann N, Hubbell B, Pope CA3rd, Apte JS, Brauer M, Cohen A, Weichenthal S, Coggins J, Di Q, Brunekreef B, Frostad J, Lim SS, Kan H, Walker KD, Thurston GD, Hayes RB, Lim CC, Turner MC, Jerrett M, Krewski D, Gapstur SM, Diver WR, Ostro B, Goldberg D, Crouse DL, Martin RV, Peters P, Pinault L, Tjepkema M, van Donkelaar A, Villeneuve PJ, Miller AB, Yin P, Zhou M, Wang L, Janssen NAH, Marra M, Atkinson RW, Tsang H, Quoc Thach T, Cannon JB, Allen RT, Hart JE, Laden F, Cesaroni G, Forastiere F, Weinmayr G, Jaensch A, Nagel G, Concin H, Spadaro JV.
Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter. Proc Natl Acad Sci U S A 2018;115:9592â9597.6Lelieveld J, Pozzer A, Poschl U, Fnais M, Haines A, Munzel T, Loss of life expectancy from air pollution compared to other risk factors. A worldwide perspective. Cardiovasc Res 2020;116:1910â1917.7Lelieveld J, Munzel T.
Air pollution, chronic smoking, and mortality. Eur Heart J 2019;40:3204.8Kalsch H, Hennig F, Moebus S, Mohlenkamp S, Dragano N, Jakobs H, Memmesheimer M, Erbel R, Jockel K-H, Hoffmann B, Roggenbuck U, Slomiany U, Beck EM, Offner A, Munkel S, Schrader S, Peter R, Hirche H, Meinertz T, Bode C, deFeyter PJ, Guntert B, Halli T, Gutzwiller F, Heinen H, Hess O, Klein B, Lowel H, Reiser M, Schmidt G, Schwaiger M, Steinmuller C, Theorell T, Willich SN. On behalf of the Heinz Nixdorf Recall Study Investigative Group. Are air pollution and traffic noise independently associated with atherosclerosis.
The Heinz Nixdorf Recall Study. Eur Heart J 2014;35:853â860.9Brown AL, Lam KC, van Kamp I. Quantification of the exposure and effects of road traffic noise in a dense Asian city. A comparison with western cities.
Environ Health 2015;14:22.11Kempen EV, Casas M, Pershagen G, Foraster M. WHO environmental noise guidelines for the European region. A systematic review on environmental noise and cardiovascular and metabolic effects. A summary.
Int J Environ Res Public Health 2018;15:379.12Seidler AL, Hegewald J, Schubert M, Weihofen VM, Wagner M, Droge P, Swart E, Zeeb H, Seidler A. The effect of aircraft, road, and railway traffic noise on strokeâresults of a case-control study based on secondary data. Noise Health 2018;20:152â161.13Halonen JI, Hansell AL, Gulliver J, Morley D, Blangiardo M, Fecht D, Toledano MB, Beevers SD, Anderson HR, Kelly FJ, Tonne C. Road traffic noise is associated with increased cardiovascular morbidity and mortality and all-cause mortality in London.
Eur Heart J 2015;36:2653â2661.14Héritier H, Vienneau D, Foraster M, Eze IC, Schaffner E, Thiesse L, Rudzik F, Habermacher M, Köpfli M, Pieren R, Brink M, Cajochen C, Wunderli JM, Probst-Hensch N, Röösli M. SNC Study Group. Transportation noise exposure and cardiovascular mortality. A nationwide cohort study from Switzerland.
Eur J Epidemiol 2017;32:307â315.15Cai Y, Hodgson S, Blangiardo M, Gulliver J, Morley D, Fecht D, Vienneau D, de Hoogh K, Key T, Hveem K, Elliott P, Hansell AL. Road traffic noise, air pollution and incident cardiovascular disease. A joint analysis of the HUNT, EPIC-Oxford and UK Biobank cohorts. Environ Int 2018;114:191â201.16Monrad M, Sajadieh A, Christensen JS, Ketzel M, Raaschou-Nielsen O, Tjønneland A, Overvad K, Loft S, Sørensen M.
Residential exposure to traffic noise and risk of incident atrial fibrillation. A cohort study. Environ Int 2016;92â93:457â463.17Hansell AL, Blangiardo M, Fortunato L, Floud S, de HK, Fecht D, Ghosh RE, Laszlo HE, Pearson C, Beale L, Beevers S, Gulliver J, Best N, Richardson S, Elliott P. Aircraft noise and cardiovascular disease near Heathrow airport in London.
Small area study. BMJ 2013;347:f5432.18Kempen EV, Casas M, Pershagen G, Foraster M. WHO environmental noise guidelines for the European region. A systematic review on environmental noise and cardiovascular and metabolic effects.
A summary. Int J Environ Res Public Health 2018;15:379.19Zare Sakhvidi MJ, Zare Sakhvidi F, Mehrparvar AH, Foraster M, Dadvand P. Association between noise exposure and diabetes. A systematic review and meta-analysis.
Environ Res 2018;166:647â657.20Pyko A, Eriksson C, Lind T, Mitkovskaya N, Wallas A, Ogren M, Ostenson CG, Pershagen G. Long-term exposure to transportation noise in relation to development of obesityâa cohort study. Environ Health Perspect 2017;125:117005.21Thacher JD, Hvidtfeldt UA, Poulsen AH, Raaschou-Nielsen O, Ketzel M, Brandt J, Jensen SS, Overvad K, Tjønneland A, Münzel T, Sørensen M. Long-term residential road traffic noise and mortality in a Danish cohort.
Environ Res 2020;187:109633.22Eriksson HP, Andersson E, Schioler L, Soderberg M, Sjostrom M, Rosengren A, Toren K. Longitudinal study of occupational noise exposure and joint effects with job strain and risk for coronary heart disease and stroke in Swedish men. BMJ Open 2018;8:e019160.23Stokholm ZA, Bonde JP, Christensen KL, Hansen AM, Kolstad HA. Occupational noise exposure and the risk of stroke.
Stroke 2013;44:3214â3216.24Babisch W. The noise/stress concept, risk assessment and research needs. Noise Health 2002;4:1â11.25Munzel T, Sorensen M, Gori T, Schmidt FP, Rao X, Brook FR, Chen LC, Brook RD, Rajagopalan S. Environmental stressors and cardio-metabolic disease.
Part II-mechanistic insights. Eur Heart J 2016;38:557â564.26Hahad O, Prochaska JH, Daiber A, Münzel T. Environmental noise-induced effects on stress hormones, oxidative stress, and vascular dysfunction. Key factors in the relationship between cerebrocardiovascular and psychological disorders.
Oxid Med Cell Longev 2019;2019:1â13.27Osborne MT, Radfar A, Hassan MZO, Abohashem S, Oberfeld B, Patrich T, Tung B, Wang Y, Ishai A, Scott JA, Shin LM, Fayad ZA, Koenen KC, Rajagopalan S, Pitman RK, Tawakol A. A neurobiological mechanism linking transportation noise to cardiovascular disease in humans. Eur Heart J 2020;41:772â782.28Münzel T, Daiber A, Steven S, Tran LP, Ullmann E, Kossmann S, Schmidt FP, Oelze M, Xia N, Li H, Pinto A, Wild P, Pies K, Schmidt ER, Rapp S, Kröller-Schön S. Effects of noise on vascular function, oxidative stress, and inflammation.
Mechanistic insight from studies in mice. Eur Heart J 2017;38:2838â2849.29Kröller-Schön S, Daiber A, Steven S, Oelze M, Frenis K, Kalinovic S, Heimann A, Schmidt FP, Pinto A, Kvandova M, Vujacic-Mirski K, Filippou K, Dudek M, Bosmann M, Klein M, Bopp T, Hahad O, Wild PS, Frauenknecht K, Methner A, Schmidt ER, Rapp S, Mollnau H, Münzel T. Crucial role for Nox2 and sleep deprivation in aircraft noise-induced vascular and cerebral oxidative stress, inflammation, and gene regulation. Eur Heart J 2018;39:3528â3539.30Herzog J, Schmidt FP, Hahad O, Mahmoudpour SH, Mangold AK, Garcia Andreo P, Prochaska J, Koeck T, Wild PS, Sørensen M, Daiber A, Münzel T.
Acute exposure to nocturnal train noise induces endothelial dysfunction and pro-thromboinflammatory changes of the plasma proteome in healthy subjects. Basic Res Cardiol 2019;114:46.31Brook RD, Rajagopalan S, Pope CA3rd, Brook JR, Bhatnagar A, Diez-Roux AV, Holguin F, Hong Y, Luepker RV, Mittleman MA, Peters A, Siscovick D, Smith SCJr, Whitsel L, Kaufman JD, American Heart Association Council on Epidemiology and Prevention, Council on the Kidney in Cardiovascular Disease, and Council on Nutrition, Physical Activity and Metabolism. Particulate matter air pollution and cardiovascular disease. An update to the scientific statement from the American Heart Association.
Circulation 2010;121:2331â2378.32Al-Kindi S, Brook RD, Biswal S, Rajagopalan S. Environmental determinants of cardiovascular disease. Lessons learned from air pollution. Nat Rev Cardiol 2020;17:656â672.33Lelieveld J, Klingmuller K, Pozzer A, Poschl U, Fnais M, Daiber A, Munzel T.
Cardiovascular disease burden from ambient air pollution in Europe reassessed using novel hazard ratio functions. Eur Heart J 2019;40:1590â1596.34Miller MR, Newby DE. Air pollution and cardiovascular disease. Car sick.
Cardiovasc Res 2020;116:279â294.35Rajagopalan S, Huang S, Brook RD. Flattening the curve in anti inflammatory drugs using personalised protective equipment. Lessons from air pollution. Heart 2020;106:1286â1288.36Langrish JP, Li X, Wang S, Lee MM, Barnes GD, Miller MR, Cassee FR, Boon NA, Donaldson K, Li J, Li L, Mills NL, Newby DE, Jiang L.
Reducing personal exposure to particulate air pollution improves cardiovascular health in patients with coronary heart disease. Environ Health Perspect 2012;120:367â372.37Yang X, Jia X, Dong W, Wu S, Miller MR, Hu D, Li H, Pan L, Deng F, Guo X. Cardiovascular benefits of reducing personal exposure to traffic-related noise and particulate air pollution. A randomized crossover study in the Beijing subway system.
Indoor Air 2018;28:777â786.38Cherrie JW, Apsley A, Cowie H, Steinle S, Mueller W, Lin C, Horwell CJ, Sleeuwenhoek A, Loh M. Effectiveness of face masks used to protect Beijing residents against particulate air pollution. Occup Environ Med 2018;75:446â452.39United States Department of Environmental Protection. Our Built and Natural Environments.
A Technical Review of the Interactions Among Land Use, Transportation, and Environmental Quality. 2013. U.S. Environmental Protection Agency, Washington, USA.40Hamidi S, Ewing R, Tatalovich Z, Grace JB, Berrigan D.
Associations between Urban Sprawl and Life Expectancy in the United States. Int J Environ Res Public Health 2018;15:861.41Hankey S, Marshall JD. Urban form, air pollution, and health. Curr Environ Health Rep 2017;4:491â503.42Heo S, Bell ML.
The influence of green space on the short-term effects of particulate matter on hospitalization in the U.S. For 2000â2013. Environ Res 2019;174:61â68.43Yitshak-Sade M, James P, Kloog I, Hart JE, Schwartz JD, Laden F, Lane KJ, Fabian MP, Fong KC, Zanobetti A. Neighborhood greenness attenuates the adverse effect of PM2.5 on cardiovascular mortality in neighborhoods of lower socioeconomic status.
Int J Environ Res Public Health 2019;16:814.44Mitchell R, Popham F. Effect of exposure to natural environment on health inequalities. An observational population study. Lancet 2008;372:1655â1660.45Giles-Corti B, Vernez-Moudon A, Reis R, Turrell G, Dannenberg AL, Badland H, Foster S, Lowe M, Sallis JF, Stevenson M, Owen N.
City planning and population health. A global challenge. Lancet 2016;388:2912â2924.46Münzel T, Steven S, Frenis K, Lelieveld J, Hahad O, Daiber A. Environmental factors such as Noise and Air Pollution and Vascular Disease.
Antioxid Redox Signal 2020;33:581â601.47Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention &.
Rehabilitation (EACPR). Eur Heart J 2016;37:2315â2381. Author notes© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
For commercial re-use, please contact journals.permissions@oup.com.
With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article.âFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.It is well established that prevention of cardiovascular diseases (CVDs) is based on optimization of lifestyle including Can i buy viagra at cvs abstinence from smoking, regular physical activity, and an optimal diet.1â3 Nevertheless, growing evidence suggests that some risk factors, such as air pollution4 and social isolation,5 cannot be modified by single individuals but only by a symbicort 160mcg 4.5mcg inhaler price coordinated effort aimed to improve social care and healthcare organization. This is a Focus Issue on prevention and epidemiology assessing these important risk factors, which are beyond the reach of single individuals. It also provides novel information on the role of new biomarkers and of proteomics in risk stratification of CVDs and symbicort 160mcg 4.5mcg inhaler price dementia.The first contribution is a State of the Art Review entitled âReduction of environmental pollutants for prevention of cardiovascular disease. Itâs time to actâ by Thomas Münzel from the Johannes Gutenberg Universität in Mainz, Germany and colleagues.6 The authors note that environmental risk factors are increasingly recognized as important determinants of CVD. While the symbicort 160mcg 4.5mcg inhaler price contributions of diet, exercise, and smoking are well established, the contribution by factors such as noise and air pollution are often not acknowledged, despite the recognition that they represent the two most common and pervasive environmental risk factors globally.
Recent data indicate that air pollution-attributable premature deaths approach 9 million per year globally (mostly cardiovascular causes), accounting for a loss of life expectancy that rivals that of tobacco smoking. The health burden due to noise pollution is mostly based on loss of healthy life years, amounting to symbicort 160mcg 4.5mcg inhaler price several hundreds of millions of disability-adjusted life years per year. Importantly, health effects of both air pollution and traffic noise are observed at levels of exposure well below the regulatory thresholds, currently assumed to be safe. Mechanistic evidence in animal models, natural intervention studies, and quasi-experimental studies with air pollution mitigation support a direct pathophysiological role for air pollution in CVD. In this current opinion, the epidemiological and symbicort 160mcg 4.5mcg inhaler price mechanistic evidence in support of an association between noise and air pollution with CVD and metabolic disease, and comprehensive mitigation measures, is discussed.
Increased awareness of the health burden posed by these risk factors and incorporation in traditional medical guidelines will help propel legislation to reduce them and significantly improve cardiovascular health.In the era of personalized medicine, it is of utmost importance to be able to identify subjects at highest cardiovascular risk. To date, single biomarkers have failed to markedly improve estimation of cardiovascular risk symbicort 160mcg 4.5mcg inhaler price. Using novel technology, simultaneous assessment of large numbers of biomarkers may hold promise to improve prediction.7 In a clinical research article entitled âImproved cardiovascular risk prediction using targeted plasma proteomics in primary preventionâ, Renate Hoogeveen from the University of Amsterdam in the Netherlands and colleagues compared a protein-based risk model with a model using traditional risk factors in predicting cardiovascular events in the primary prevention setting of the EPIC-Norfolk study, followed by validation in the PLIC cohort.8 Using the proximity extension assay, >350 proteins were measured in a nested caseâcontrol sample of â¼1500 individuals. Using tree-based ensemble and symbicort 160mcg 4.5mcg inhaler price boosting methods, the authors constructed a protein-based prediction model, an optimized clinical risk model, and a model combining both. In the derivation cohort (EPIC-Norfolk) they defined a panel of 50 proteins, which outperformed the clinical risk model in prediction of myocardial infarction, with an area under the curve (AUC) of 0.754 during a median follow-up of 20 years (Figure 1).
The predictive value of the protein panel was confirmed to be superior to the clinical symbicort 160mcg 4.5mcg inhaler price risk model in the validation cohort (PLIC). Figure 1Receiver operating characteristics of prediction models. (A) Prediction of events with protein, clinical risk, and the combined model in the derivation cohort. (B) Short-term prediction symbicort 160mcg 4.5mcg inhaler price (<3 years) of events with protein, clinical risk, and the combined model in the derivation cohort. (C) Prediction of events with protein, clinical risk, and the combined model in the validation cohort.
AUC, area under the symbicort 160mcg 4.5mcg inhaler price curve. ROC, receiver operating characteristic (from Hoogeveen RM, Belo Pereira JP, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw K-T, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using targeted plasma proteomics in symbicort 160mcg 4.5mcg inhaler price primary prevention. See pages 3998â4007).Figure 1Receiver operating characteristics of prediction models. (A) Prediction of events with protein, clinical risk, and the combined model in the derivation cohort.
(B) Short-term prediction (<3 symbicort 160mcg 4.5mcg inhaler price years) of events with protein, clinical risk, and the combined model in the derivation cohort. (C) Prediction of events with protein, clinical risk, and the combined model in the validation cohort. AUC, area under the curve symbicort 160mcg 4.5mcg inhaler price. ROC, receiver operating characteristic (from Hoogeveen RM, Belo Pereira JP, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw K-T, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using targeted symbicort 160mcg 4.5mcg inhaler price plasma proteomics in primary prevention.
See pages 3998â4007).The authors conclude that in a primary prevention setting, a proteome-based model outperforms a model comprising clinical risk factors in predicting the risk of cardiovascular events, but validation in a large prospective primary prevention cohort is required in order to address the value for future clinical implementation in guidelines. The manuscript is accompanied by an Editorial by Peter Ganz from the University of California San Francisco symbicort 160mcg 4.5mcg inhaler price in California, USA and colleagues.9 The authors note that data accumulating in ongoing studies will establish whether the great potential of proteomics to improve healthcare is fulfilled.The risk and burden of CVD are higher in homeless than in housed individuals, but population-based analyses are lacking. In a clinical research article entitled âPrevalence, incidence, and outcomes across cardiovascular diseases in homeless individuals using national linked electronic health recordsâ, Amitava Banerjee from the University College London, UK and colleagues investigated prevalence, incidence, and outcomes across a range of specific CVDs among homeless individuals.10 Using linked UK primary care electronic health records and validated phenotypes, the authors identified â¼8500 homeless individuals aged â¥16 years between 1998 and 2019, and â¼32 000 age- and sex-matched housed controls. Comorbidities and risk factors were significantly more prevalent in homeless than in housed people. In addition, CVD prevalence, incidence, and 1-year mortality risk (adjusted hazard ratio symbicort 160mcg 4.5mcg inhaler price 1.64) were higher in homeless than in housed people.The authors conclude that inclusion healthcare and social care strategies should reflect this high preventable and treatable burden observed in homeless people, which is increasingly important in the current anti inflammatory drugs context.
This manuscript is accompanied by an Editorial by Elias Mossialos and Sahan Jayawardana from the London School of Economics and Political Science in the UK.11 The authors note that close coordination is required between agencies and services to ensure a coherent pathway to address the needs of people at risk of becoming homeless.Dementia is a major global challenge for healthcare and social care in ageing populations.12 A third of all dementia cases may be preventable due to cardiovascular risk factors. In a clinical research article entitled âImpact of cardiovascular risk factors and genetics on 10-year absolute symbicort 160mcg 4.5mcg inhaler price risk of dementia. Risk charts for targeted preventionâ, Ruth Frikke-Schmidt from the Rigshospitalet in Copenhagen, Denmark and colleagues note that intensive multidomain intervention trials targeting primarily cardiovascular risk factors show improved cognitive function in people at risk.13 Such interventions, however, would be expensive to implement in all individuals at risk, representing an unrealistic economic task for most societies. Therefore, a symbicort 160mcg 4.5mcg inhaler price risk score identifying high-risk individuals is warranted. In 61 500 individuals from two prospective cohorts of the Danish general population, the authors generated 10-year absolute risk scores for all-cause dementia from cardiovascular risk factors and genetics.
In both sexes, symbicort 160mcg 4.5mcg inhaler price 10-year absolute risk of all-cause dementia increased with increasing age, number of apolipoprotein E (APOE) É4 alleles, number of genome-wide association study (GWAS) risk alleles, and cardiovascular risk factors. The highest 10-year absolute risks of all-cause dementia seen in female smokers who had diabetes, low education, APOE É44 genotype, and 22â31 GWAS risk alleles were 6, 23, 48, and 66% in those aged 50â59, 60â69, 70â79, and 80â100, respectively. Corresponding values for men were 5, 19, 42, and 60%, respectively.The authors conclude that 10-year absolute risk charts for dementia will facilitate identification of high-risk individuals, those who probably will benefit the most from an early intervention against cardiovascular risk factors. The manuscript is accompanied by an Editorial by Andrew Sommerlad from the University College London in the UK, and Andrew Sommerlad.14 The authors note that the economic, social, and individual costs of dementia mean that its prevention should be a priority for all those at risk as well as policymakers and clinicians.The global anti inflammatory drugs symbicort is caused by the anti-inflammatories symbicort entering human cells using angiotensin-converting enzyme 2 (ACE2) as a cell surface receptor.15,16 ACE2 is shed to the circulation and a higher plasma level of soluble ACE2 (sACE2) might reflect a higher symbicort 160mcg 4.5mcg inhaler price cellular expression of ACE2. In a research article âAngiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillationâ Lars Wallentin from the Uppsala Clinical Research Center in Sweden and colleagues explored the associations between sACE2 levels and clinical factors, cardiovascular biomarkers, and genetic variability.17 Plasma and DNA samples were obtained from â¼5000 elderly patients with atrial fibrillation from two international cohorts.
The authors found that higher levels of sACE2 were symbicort 160mcg 4.5mcg inhaler price significantly associated with male sex, CVD, diabetes, and higher age. The sACE2 level was also most strongly associated with the levels of growth differentiation factor 15 (GDF-15), N-terminal probrain natriuretic peptide (NT-proBNP), and high-sensitive cardiac troponin T (hs-cTnT). When adjusting for these biomarkers, only male sex remained symbicort 160mcg 4.5mcg inhaler price associated with sACE2. The authors found no significant genetic regulation of the sACE2 level (Figure 2).The authors conclude that the levels of GDF-15 and NT-proBNP, which are associated with both the sACE2 level and a higher risk for mortality and CVD, might contribute to better identification of risk for severe anti inflammatory drugs . The manuscript is accompanied by an Editorial by Dirk J.
Van Veldhuisen from the University Hospital Groningen in the Netherlands, and colleagues who highlight that this study is important and timely because it contributes to the growing body of research symbicort 160mcg 4.5mcg inhaler price aimed at deciphering ACE2 pathophysiology and possible implications in anti inflammatory drugs care.18 Figure 2Summarizing concept on association between sACE2 and biological aging (from Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillation. See pages 4037â4046).Figure 2Summarizing concept on association between sACE2 and biological aging (from Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz symbicort 160mcg 4.5mcg inhaler price MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillation. See pages symbicort 160mcg 4.5mcg inhaler price 4037â4046).In a State of the Art review entitled âHigh-sensitivity cardiac troponin assays for cardiovascular risk stratification in the general populationâ Dimitrios Farmakis from the University of Cyprus Medical School in Nicosia, Cyprus and colleagues note that cTnI and cTnT have long been the most successful cardiac-specific circulating biomarkers in cardiovascular medicine, having dramatically changed the diagnosis of acute myocardial infarction, while being independent predictors of outcome in several cardiac and non-cardiac conditions.19 The latest generation hs-cTn assays demonstrate both enhanced diagnostic performance and improved analytical performance, with the ability to measure detectable concentrations in a substantial proportion of the asymptomatic and presumably healthy populations.
Given this unique analytical feature, recent evidence suggests that hs-cTn can be used for the stratification of cardiovascular risk in the general population. Hs-cTn predicts future cardiovascular events, is responsive to preventive pharmacological or symbicort 160mcg 4.5mcg inhaler price lifestyle interventions, changes in parallel to risk modifications, and offers incremental risk prediction when added to well-established prognosticators. They conclude that implementation of cardiovascular risk stratification and prevention strategies incorporating hs-cTn requires further investigation to define the optimal target populations, timing of measurement, and preventive interventions.Finally, in another State of the Art review entitled âEffects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomesâ Thomas Münzel from the Johannes Gutenberg Universität in Mainz, Germany, and colleagues point out that tobacco smoking is a leading cause of non-communicable disease globally and is a major risk factor for CVD and lung disease.20 Importantly, recent data form the World Health Organization (WHO) indicate that in the last two decades global tobacco use has significantly dropped, which was largely driven by decreased numbers of female smokers. Despite such advances, the use of e-cigarettes and waterpipes (shisha, hookah, and narghile) is an emerging trend, especially among younger generations. A growing body of evidence suggests that e-cigarettes are not a harm-free alternative to tobacco cigarettes and there is considerable debate as to whether e-cigarettes are saving symbicort 160mcg 4.5mcg inhaler price smokers or generating new addicts.
The authors provide an updated overview of the impact of tobacco/shisha smoking and e-cigarette vaping on endothelial function, a biomarker for early, subclinical, atherosclerosis from human and animal studies as well as of the emerging adverse effects on the proteome, transcriptome, epigenome, microbiome, and the circadian clock. The authors symbicort 160mcg 4.5mcg inhaler price also discuss the impact of the toxic constituents of these products on endothelial function and subsequent CVD. In addition, they provide an update on current recommendations, regulation, and advertising with focus on the USA and Europe.The editors hope that readers of this issue of the European Heart Journal will find it of interest. References1Grant PJ, symbicort 160mcg 4.5mcg inhaler price Cosentino F. The 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD.
New features symbicort 160mcg 4.5mcg inhaler price and the âTen Commandmentsâ of the 2019 Guidelines are discussed by Professor Peter J. Grant and Professor Francesco Cosentino, the Task Force chairmen. Eur Heart J 2019;40:3215â3217.2Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O. ESC Scientific symbicort 160mcg 4.5mcg inhaler price Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias.
Lipid modification to reduce symbicort 160mcg 4.5mcg inhaler price cardiovascular risk. Eur Heart J 2020;41:111â188.3Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S. ESC Scientific symbicort 160mcg 4.5mcg inhaler price Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts).
Developed with the special contribution of the European Association for Cardiovascular Prevention symbicort 160mcg 4.5mcg inhaler price &. Rehabilitation (EACPR). Eur Heart J symbicort 160mcg 4.5mcg inhaler price 2016;37:2315â2381.4Dominguez-Rodriguez A, RodrÃguez S, Hernández-Vaquero D. Air pollution is intimately linked to global climate change. Change in symbicort 160mcg 4.5mcg inhaler price Cardiovascular Disease Statistics 2019.
Eur Heart J 2020;41:2601.5Yusuf S, Hawken S, Ãunpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L. INTERHEART Study symbicort 160mcg 4.5mcg inhaler price Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study). Caseâcontrol study. Lancet 2004;364:937â952.6Münzel T, Miller MR, Sørensen M, Lelieveld symbicort 160mcg 4.5mcg inhaler price J, Daiber A, Rajagopalan S.
Reduction of environmental pollutants for prevention of cardiovascular disease. Itâs time to act symbicort 160mcg 4.5mcg inhaler price. Eur Heart J 2020;41:3989â3997.7Ganz P, Heidecker B, Hveem K, Jonasson C, Kato S, Segal MR, Sterling DG, Williams SA. Development and validation of a protein-based risk score for cardiovascular outcomes among patients with stable coronary heart symbicort 160mcg 4.5mcg inhaler price disease. JAMA 2016;315:2532â2541.8Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG.
Improved symbicort 160mcg 4.5mcg inhaler price cardiovascular risk prediction using targeted plasma proteomics in primary prevention. Eur Heart J 2020;41:3998â4007.9Ganz P, Deo R, Dubin RF. Proteomics for personalized cardiovascular risk assessment. In pursuit of the symbicort 160mcg 4.5mcg inhaler price Holy Grail. Eur Heart J 2020;41:4008â4010.10Nanjo A, Evans H, Direk K, Hayward A, Story A, Banerjee A.
Prevalence, incidence, symbicort 160mcg 4.5mcg inhaler price and outcomes across cardiovascular diseases in homeless individuals using national linked electronic health records. Eur Heart J 2020;41:4011â4020.11Jayawardana S, Mossialos E. Lives symbicort 160mcg 4.5mcg inhaler price cut short. Socioeconomic inequities, homelessness, and cardiovascular disease. Eur Heart J 2020;41:4021â4022.12Lüscher TF.
The heart and the symbicort 160mcg 4.5mcg inhaler price brain. Cardiovascular risk factors, atrial fibrillation, and dementia. Eur Heart symbicort 160mcg 4.5mcg inhaler price J 2019;40:2271â2275,13Rasmussen IJ, Rasmussen KL, Nordestgaard BG, Tybjærg-Hansen A, Frikke-Schmidt R. Impact of cardiovascular risk factors and genetics on 10-year absolute risk of dementia. Risk charts for targeted symbicort 160mcg 4.5mcg inhaler price prevention.
Eur Heart J 2020;41:4024â4033.14Sommerlad A, Mukadam N. Evaluating risk of dementia symbicort 160mcg 4.5mcg inhaler price in older people. A pathway to personalized prevention?. Eur Heart J 2020;41:4034â4036.15Xiong TY, Redwood S, Prendergast B, Chen M. anti-inflammatorieses and the symbicort 160mcg 4.5mcg inhaler price cardiovascular system.
Acute and long-term implications. Eur Heart symbicort 160mcg 4.5mcg inhaler price J. 2020;41:1798â1800.16Pericà s JM, Hernandez-Meneses M, Sheahan TP, Quintana E, Ambrosioni J, Sandoval E, Falces C, Marcos MA, Tuset M, Vilella A, Moreno A, Miro JM. Hospital ClÃnic symbicort 160mcg 4.5mcg inhaler price Cardiovascular s Study Group. anti inflammatory drugs.
From epidemiology to treatment. Eur Heart symbicort 160mcg 4.5mcg inhaler price J. 2020;41:2092â2112.17Wallentin L, Lindbäck J, Eriksson N, Hijazi Z, Eikelboom JW, Ezekowitz MD, Granger CB, Lopes RD, Yusuf S, Oldgren J, Siegbahn A. Angiotensin-converting enzyme symbicort 160mcg 4.5mcg inhaler price 2 (ACE2) levels in relation to risk factors for anti inflammatory drugs in two large cohorts of patients with atrial fibrillation. Eur Heart J 2020;41:4037â4046.18Sama IE, Voors AA, van Veldhuisen DJ.
New data on symbicort 160mcg 4.5mcg inhaler price soluble ACE2 in patients with atrial fibrillation reveal potential value for treatment of patients with anti inflammatory drugs and cardiovascular disease. Eur Heart J 2020;41:4047â4049.19Farmakis D, Mueller C, Apple FS. High-sensitivity cardiac troponin symbicort 160mcg 4.5mcg inhaler price assays for cardiovascular risk stratification in the general population. Eur Heart J 2020;41:4050.20Münzel T, Hahad O, Kuntic M, Keaney JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes.
Eur Heart J symbicort 160mcg 4.5mcg inhaler price 2020;41:4057. Published on behalf of the European Society of Cardiology. All rights symbicort 160mcg 4.5mcg inhaler price reserved. © The Author(s) 2020. For permissions, symbicort 160mcg 4.5mcg inhaler price please email.
Journals.permissions@oup.com.Abstract IntroductionCardiovascular disease (CVD) represents the result of underlying genetic predisposition and lifetime exposure to multiple environmental factors. The past century symbicort 160mcg 4.5mcg inhaler price has seen a revolution in our understanding of the importance of modifiable risk factors such as diet, exercise, and smoking. Exposure to environmental pollutants, be it in the air, water, or physical environment, is increasingly recognized as a silent, yet important determinant of CVD.1 The quote âgenetics loads the gun but the environment pulls the triggerâ, put forward by G.A. Bray and F. Collins, exemplifies the complex relationship between human disease and symbicort 160mcg 4.5mcg inhaler price the environment.
The cardiovascular system is highly vulnerable to a variety of environmental insults, including tobacco smoke, solvents, pesticides, and other inhaled or ingested pollutants, as well as extremes in noise and temperature. While our understanding of multiple environmental factors continues to evolve, it is estimated that symbicort 160mcg 4.5mcg inhaler price environmental air pollution and noise pollution alone may contribute to a substantial burden attributable to environmental factors as we currently understand them. It is important to note that noise and air pollution can have many of the same sources such as heavy industry, road and aircraft vehicles. In a recent in-depth report, the European Commission acknowledged that the societal costs for the combination noise and air pollution are nearly 1 trillion Euros, while the costs for alcohol and smoking are considerably less (50â120 symbicort 160mcg 4.5mcg inhaler price and 540 billion Euro, respectively, see https://ec.europa.eu/environment/integration/research/newsalert/pdf/air_noise_pollution_socioeconomic_status_links_IR13_en.pdf). The World Health Organization (WHO) calculates that 12.6 million premature deaths per year are attributable to unhealthy environments, 8.2 million of which are due to non-communicable disease, with CVD (including stroke) being the largest contributor, accounting for nearly 5 million of these deaths.2 Among all environmental pollutants, poor air quality is the most important risk factor, and ambient air pollution due to particulate matter <2.5âµm (PM2.5) exposure ranks 5th among all global risk factors in 2015, leading to 4.2 million deaths annually as estimated by the Global Burden of Disease study.3 Nine out of 10 people worldwide are exposed to ambient air pollutant levels above WHO guidelines (>10âµg/m).3,4 Using a novel exposure-response hazard function (global estimate of exposure mortality model) to estimate global mortality attributable to air pollution, Burnett et al.5 and Lelieveld et al.6 found that around 9 million global premature deaths (790 000 excess deaths in Europe alone) were attributable to air pollution,7 numbers that are well comparable to that of smoking.6 These figures are substantially higher than those estimated by the WHO and Global Burden of Disease study.2,3Ambient noise is the other omnipresent exposure with emerging data suggesting a large attributable burden of disability to this factor in many urban environments.
In Western Europe, it is estimated that around 1.6 million healthy life years are lost every year due to noise. It is estimated that a large part of the European population is exposed to symbicort 160mcg 4.5mcg inhaler price noise originating from road traffic at levels exceeding 55 decibels [dB(A), A-weighted decibel scale adapted to the human hearing frequencies]. 20% exposed to levels exceeding 65âdB(A) during the daytime. And 30% of symbicort 160mcg 4.5mcg inhaler price the population is exposed to levels exceeding 55âdB(A) (see https://www.eea.europa.eu/publications/environmental-noise-in-europe). In this review, we will focus on the cardiovascular effects of ambient air pollution and noise pollution as prototypical environmental factors that provide important lessons to facilitate understanding of the outsize effects of the environment on susceptibility to CVD.
The pathophysiology, epidemiology, mitigation measures, and future challenges for these two common yet pervasive environmental factors are discussed in detail.In many parts of the world, a substantial portion of the urban population is exposed to road traffic noise at levels exceeding 55âdB(A).8 In cities in Asia, symbicort 160mcg 4.5mcg inhaler price the proportion of the population reaching Lden levels (dayâeveningânight level, i.e. The average sound pressure level measured over a 24âh period with adjustment for more detrimental health effects of nocturnal noise) of 60â64âdB is very high.9 In contrast to the relatively straightforward classification of noise, air pollution is intrinsically complex and defy easy classification. From a regulatory perspective, âcriteriaâ air pollutants allow health-based and/or environmentally based guidelines for setting permissible levels.10 These include carbon monoxide, lead, nitrogen oxides, ground-level ozone, particle pollution (often referred to as symbicort 160mcg 4.5mcg inhaler price PM), and sulphur oxides. Particulate matter is categorized based on its aerodynamic diameter. ¤10âμm [thoracic particles (PM10)], â¤2.5âμm [fine particles (PM2.5)], â¤0.1âμm [ultrafine particles (UFP)], and between 2.5 and 10âμm [coarse particles (PM2.5â10)].
Although âcriteriaâ pollutants are regulated individually, it is anticipated that the effects of air pollution are driven by the complex interaction of particulate and gaseous components in mixtures and that symbicort 160mcg 4.5mcg inhaler price smaller particles (e.g. UFP) are more detrimental then larger ones.There is substantial spatial and temporal variation of both noise and air pollution. Traffic-related pollutants and noise often peaking during the late morning and symbicort 160mcg 4.5mcg inhaler price evening rush hours. Gradients for both noise and air pollutants are also dependent upon meteorological conditions, including diurnal changes in vertical mixing height, wind speed, and temperature. In the case of noise, the gradients are substantial as the intensity of noise decreases exponentially with the distance from symbicort 160mcg 4.5mcg inhaler price its source.
The gradients for air pollution from their source may also differ depending upon the pollutant. Traffic factors, such as the speed, symbicort 160mcg 4.5mcg inhaler price traffic load, etc., may also differentially affect noise and traffic-related air pollution. During traffic congestion, when traffic is at standstill or at lower engine speeds, noise levels may be lower, but emissions may be dramatically higher, contributing to marked surges in traffic-related air pollutants. In contrast, when traffic is moving well, noise levels may be higher, but emissions may be lower. Environmental factors such as road conditions, noise barriers, and surrounding buildings are well known to influence traffic noise but may not symbicort 160mcg 4.5mcg inhaler price influence air pollution substantially.The highly associated nature of traffic noise and air pollution makes it challenging to isolate their independent effects on cardiovascular events in epidemiological studies.
A few studies have attempted to assess the independent contribution of noise from air pollution and vice versa. The results are, however, somewhat variable, with some studies demonstrating an independent effect of noise and/or air pollution on symbicort 160mcg 4.5mcg inhaler price cardiovascular morbidity and mortality, while others find marked attenuation of effects after adjusting for the other. Whether noise and air pollution have differing, additive, synergistic, and/or confounding effects upon cardiovascular health is still incompletely understood. Also of great symbicort 160mcg 4.5mcg inhaler price importance in all air pollution and noise exposure studies is the co-linearity of these risk factors to other confounders (e.g. Lower socio-economic status, psychosocial stressors, other poorly understood environmental variables and adverse lifestyle factors) that often go hand-in-hand with pollutants.
Pathophysiology and epidemiology of noise and cardiovascular disease EpidemiologyDuring the last decade, a number of epidemiological studies have investigated effects of transportation noise on risk for CVD. In 2018, a systematic review by WHO found that there was substantial evidence to conclude that road traffic noise increases the risk for ischaemic heart disease, with an 8% higher risk per 10âdB higher noise.11 For stroke, the evidence was ranked as moderate, with only one study on incidence and four on mortality.11 Subsequently, large population-based studies from Frankfurt, London, and Switzerland found road traffic noise to increase stroke incidence and/or mortality, especially symbicort 160mcg 4.5mcg inhaler price ischaemic strokes,12â14 whereas smaller cohort studies indicated no association.15 Recently, road traffic noise has been found to increase the risk for other major CVD not evaluated by WHO, most importantly heart failure and atrial fibrillation.14,16 Aircraft noise has also been associated with higher CVD incidence and mortality,14,17 but due to a limited number of studies, the evidence is still rated low to moderate.18Epidemiological studies have linked transportation noise with a number of major cardiovascular risk factors, most consistently obesity and diabetes.19,20 Also, many studies investigated effects of noise on hypertension, and although a meta-analysis of 26 studies found that road traffic noise was associated with higher prevalence of hypertension,11 studies on incidence are still few and inconsistent.Ambient air pollution and traffic noise, especially from roads, are correlated and suspected of being associated with the same CVD, and therefore mutual adjustment is highly important. Most recent studies on noise and CVD adjust for air pollution and generally the results are found to be robust to the adjustment, suggesting that transportation noise is indeed an independent risk factor for CVD.21Another noise source investigated in relation to CVD risk is occupational noise. An exposure mainly occurring symbicort 160mcg 4.5mcg inhaler price during daytime. Most existing studies are cross-sectional, and results from a few prospective studies providing conflicting evidence, with some studies indicating an association with CVD,22 whereas others finding no association,23 stressing the need for more well-designed prospective studies.
PathophysiologyAccording to the noise stress reaction model introduced by Babisch,24non-auditory health effects of noise have been demonstrated to activate a so-called âindirect pathwayâ, which in turn represents the cognitive perception of the sound, and symbicort 160mcg 4.5mcg inhaler price its subsequent cortical activation is related to emotional responses such as annoyance and anger (reviewed in Ref. 25) This stress reaction chain can initiate physiological stress responses, involving the hypothalamus, the limbic system, and the autonomic nervous system with activation of the hypothalamusâpituitaryâadrenal (HPA) axis and the sympatheticâadrenalâmedulla axis, and is associated with an increase in heart rate and in levels of stress hormones (cortisol, adrenalin, and noradrenaline) enhanced platelet reactivity, vascular inflammation, and oxidative stress (see Figure 1). While the conscious experience with noise might be the primary source of stress reactions during daytime (for transportation and occupational noise), the sub-conscious biological response during night-time in sleeping subjects, at much lower transportation noise levels, is thought to play an important role in pathophysiology, particularly through disruption of sleepâwake cycle, diurnal variation, and perturbation of symbicort 160mcg 4.5mcg inhaler price time periods critical for physiological and mental restoration. Recent human data provided a molecular proof of the important pathophysiological role of this âindirect pathwayâ by identifying amygdalar activation (using 18F-FDGPET/CT imaging) by transportation noise in 498 subjects, and its association with arterial inflammation and major adverse cardiovascular events.27 These data are indeed consistent with animal experiments demonstrating an increased release of stress hormones (catecholamines and cortisol), higher blood pressure, endothelial dysfunction,28 neuroinflammation, diminished neuronal nitric oxide synthase (nNOS) expression as well as cerebral oxidative stress in aircraft noise-exposed mice.29 These changes were substantially more pronounced when noise exposure was applied during the sleep phase (reflecting night-time noise exposure) and was mostly prevented in mice with genetic deletion or pharmacological inhibition of the phagocytic NADPH oxidase (NOX-2).29 These studies also revealed substantial changes in the gene regulatory network by noise exposure, especially within inflammatory, antioxidant defence, and circadian clock pathways (Figure 1).28,29 The conclusions from these experiments are supportive of a role for shortened sleep duration and sleep fragmentation in cerebrovascular oxidative stress and endothelial dysfunction. Figure 1The key mechanisms of the adverse health effects of traffic noise exposure.
Environmental noise exposure causes mental stress responses, a neuroinflammatory symbicort 160mcg 4.5mcg inhaler price phenotype, and cognitive decline. This may lead to manifest psychological disorders and mental diseases or, via stress hormone release and induction of potent vasoconstrictors, to vascular dysfunction and damage. All of these mechanisms initiate cardio-metabolic risk factors that lead symbicort 160mcg 4.5mcg inhaler price to manifest end organ damage. Of note, chronic cardio-metabolic diseases often are associated with psychological diseases and vice versa.26 ⢠ACTH, adrenocorticotropic hormone. ADH, antidiuretic hormone symbicort 160mcg 4.5mcg inhaler price (vasopressin).
ATII, angiotensin II. CRH, corticotropin-releasing symbicort 160mcg 4.5mcg inhaler price hormone. ENOS, endothelial nitric oxide synthase. ET-1, endothelin-1;NO, nitric oxide. NOX-2, phagocytic NADPH symbicort 160mcg 4.5mcg inhaler price oxidase (catalytic subunit).Figure 1The key mechanisms of the adverse health effects of traffic noise exposure.
Environmental noise exposure causes mental stress responses, a neuroinflammatory phenotype, and cognitive decline. This may lead to manifest psychological disorders and mental symbicort 160mcg 4.5mcg inhaler price diseases or, via stress hormone release and induction of potent vasoconstrictors, to vascular dysfunction and damage. All of these mechanisms initiate cardio-metabolic risk factors that lead to manifest end organ damage. Of note, chronic cardio-metabolic diseases often are associated with psychological diseases and vice versa.26 symbicort 160mcg 4.5mcg inhaler price ⢠ACTH, adrenocorticotropic hormone. ADH, antidiuretic hormone (vasopressin).
ATII, angiotensin II. CRH, corticotropin-releasing symbicort 160mcg 4.5mcg inhaler price hormone. ENOS, endothelial nitric oxide synthase. ET-1, endothelin-1;NO, symbicort 160mcg 4.5mcg inhaler price nitric oxide. NOX-2, phagocytic NADPH oxidase (catalytic subunit).Likewise, we observed a significant degree of endothelial dysfunction, an increase in stress hormone release, blood pressure and a decrease in sleep quality in healthy subjects and patients with established coronary artery disease, in response to night-time aircraft noise (reviewed in Ref.25) Importantly, endothelial dysfunction was corrected by the antioxidant vitamin C indicating increased vascular oxidative stress in response to night-time aircraft noise exposure.
The important role of oxidative stress and inflammation for noise-induced cardiovascular complications was also supported by changes of the plasma proteome, centred on redox, pro-thrombotic and proinflammatory pathways, in subjects exposed to train noise for one night [mean SPL 54âdB(A)].30 Pathophysiology and epidemiology of air pollution and cardiovascular diseaseSince the publication of an American Heart Association Scientific Statement,31 there has been a consistent stream of epidemiological and mechanistic symbicort 160mcg 4.5mcg inhaler price evidence linking PM2.5, the most frequently implicated air pollution component with CVD.5,6 Mounting evidence suggests that health risks attributable to PM2.5 persist even at low levels, below WHO air quality guidelines and European standards (annual levels <10 and <25âµg/m3, respectively). Updated exposure-response dose curves suggest a robust supralinear concentration-response-curve for PM and CVD with no apparent safe threshold level.32 EpidemiologyCurrent estimates suggest air pollution is associated with around 9 million premature deaths, worldwide annually with â¼40â60% of mortality attributed to cardiovascular causes.5,33Short-term exposure (over hours or days) is associated with increased risk for myocardial infarction, stroke, heart failure, arrhythmia, and sudden death by about 1â2% per 10âµg/m3. Longer-term exposure over months or years, amplifies these risk associations, to 5â10% per symbicort 160mcg 4.5mcg inhaler price 10âµg/m3. Living in regions with poor air quality potentiates the atherosclerotic process and promotes the development of several chronic cardio-metabolic conditions (e.g. Diabetes, hypertension).Although the strength of the association for criteria air pollutants is strongest for PM2.5, there are data linking other pollutants such as nitrogen oxides (e.g.
NO2) and less consistently ozone (O3) with cardiovascular events.32 Pollutants from traffic and combustion sources are of high concern (due to high levels of ultrafine PM, toxicity symbicort 160mcg 4.5mcg inhaler price of constituents, and penetration of pollutants systemically) although precise burden estimates have yet to be established for this source. Coarse PM10 air pollution from anthropogenic sources has been associated with cardiovascular disease although sources such as agricultural emissions and crustal material are less well studied.Given the continuing links between PM2.5 and adverse cardiovascular events, even at levels substantially below 10âµg/m3, there is a need for a realistic lower limit that may strike the balance between what is reasonably possible and eliminating anthropogenic sources. It is important to keep in mind that complete elimination of all PM2.5 may not possible given that some PM2.5 is symbicort 160mcg 4.5mcg inhaler price natural. Calculations by Lelieveld et al.33 of a complete phase-out of fossil fuel-related emissions (needed to achieve the 2°C climate change goal under the Paris Agreement) demonstrated a reduction in excess mortality rate of 3.61 million per year worldwide. The increase in mean life expectancy in Europe would symbicort 160mcg 4.5mcg inhaler price be around 1.2âyears indicating a tremendous health co-benefit from the phase-out of carbon dioxide emissions.
PathophysiologyMechanistic studies, using controlled exposure studies in humans and experimental models support a causal relationship between PM and CVD. Acute exposure to air pollutants induces rapid changes that include vasoconstriction, endothelial dysfunction, arterial stiffening, arrhythmia, exacerbation of cardiac ischaemia, increased blood coagulability, and decreased fibrinolytic capacity. Additionally, long-term exposure to PM accelerates the growth and vulnerability of atherosclerotic plaques.34 A broad range of mechanisms accounts for pathophysiology at an organ and cellular level, with inflammation and oxidative stress playing key roles.25 Additionally, several convincing pathways can account for the link between inhalation of pollutants and the cardiovascular system, including passage of inflammatory (and symbicort 160mcg 4.5mcg inhaler price other) mediators into the circulation, direct passage of particles (or their constituents) into circulation, imbalance of autonomic nervous system activity, and changes to central control of endocrine systems. The contribution of individual pathways will depend on type of pollutant, the exposure (dose and duration), specific cardiovascular endpoints, and the health status of individual. Finally, the cardiovascular effects of pollutants occur in both healthy individuals and those with pre-existing cardiorespiratory disease, suggesting a potential contributory role on the induction, progression, and exacerbation of CVD.32,34 Mitigation strategies Noise mitigationIn 2020, symbicort 160mcg 4.5mcg inhaler price the European Environment Agency concluded that more than 20% of the EU population live with road traffic noise levels that are harmful to health and that this proportion is likely to increase in the future (see https://www.eea.europa.eu/publications/environmental-noise-in-europe [last accessed 17/09/2020]).
European Environment Agency also estimated that in EU, 22 million live with high railway noise and 4 million with high aircraft noise.The authorities can use different strategies to reduce levels of traffic noise (Table 1). For road traffic, the sound generated by the contact between the tires and the pavement is the dominant noise source, symbicort 160mcg 4.5mcg inhaler price at speeds above 35âkm/h for cars and above 60âkm/h for trucks. Therefore, changing to electric cars will result in only minor reductions in road traffic noise. Generally applied strategies for reducing road symbicort 160mcg 4.5mcg inhaler price traffic noise include noise barriers in densely populated areas, applying quiet road surfaces, and reducing speed, especially during night-time. Furthermore, there is a great potential in developing and using low-noise tires.
As many of these mitigation methods result in only relatively small changes in noise (Table 1), a combination of different methods is important in highly exposed areas. For aircraft noise, mitigation strategies include to minimizing overlapping of air traffic routes and housing zones, introduction of night bans, and implementation of continuous descent arrivals, which require the aircraft to approach symbicort 160mcg 4.5mcg inhaler price on steeper descents with lower, less variable throttle settings. For railway noise, replacing cast-iron block breaks with composite material, grinding of railway tracks and night bans, are among the preferred strategies for reducing noise. Lastly, installing sound-reducing windows and/or orientation of the bedroom towards the quiet side of the residence can reduce noise symbicort 160mcg 4.5mcg inhaler price exposure. Table 1Mitigation methods resulting in reduction in road traffic noise Change in noise.
Perceived change symbicort 160mcg 4.5mcg inhaler price. Methods for noise reduction. 1 dB symbicort 160mcg 4.5mcg inhaler price A very small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change. Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change.
Build noise barriers Remove 65% of symbicort 160mcg 4.5mcg inhaler price traffic 10 dB A large change. Sounds like a halving of the sound. Build high noise barriers Remove 90% symbicort 160mcg 4.5mcg inhaler price of the traffic Sound-reducing windows Change in noise. Perceived change. Methods for symbicort 160mcg 4.5mcg inhaler price noise reduction.
1 dB A very small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change. Reduce speed by symbicort 160mcg 4.5mcg inhaler price 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A large change. Sounds like symbicort 160mcg 4.5mcg inhaler price a halving of the sound.
Build high noise barriers Remove 90% of the traffic Sound-reducing windows Table 1Mitigation methods resulting in reduction in road traffic noise Change in noise. Perceived change symbicort 160mcg 4.5mcg inhaler price. Methods for noise reduction. 1 dB A symbicort 160mcg 4.5mcg inhaler price very small change. Reduce speed by 10 km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change.
Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A symbicort 160mcg 4.5mcg inhaler price large change. Sounds like a halving of the sound. Build high noise barriers Remove 90% of the traffic Sound-reducing symbicort 160mcg 4.5mcg inhaler price windows Change in noise. Perceived change.
Methods for symbicort 160mcg 4.5mcg inhaler price noise reduction. 1 dB A very small change. Reduce speed by 10 symbicort 160mcg 4.5mcg inhaler price km/h Replace all cars with electric cars Shift traffic from night-time to day-time period Remove 25% of the traffic 3 dB An audible, but small change. Reduce speed by 30 km/h Apply quiet road surfaces Use low-noise emitting tires Remove 50% of the traffic 5 dB A substantial change. Build noise barriers Remove 65% of traffic 10 dB A large change.
Sounds like a halving of symbicort 160mcg 4.5mcg inhaler price the sound. Build high noise barriers Remove 90% of the traffic Sound-reducing windows Air pollution mitigationAlthough it is widely recognized that legislation, policies, regulation, and technology, coupled with enforcement, are critical to reduction of air pollution levels, the political momentum required to accomplish this globally is currently limited. Thus, personal measures to mitigate risk take on a much greater symbicort 160mcg 4.5mcg inhaler price importance. The current experience and lessons learned with personal protective equipment and mitigation in reducing exposure to SARS-CoV2 are highly reminiscent of their use in combating air pollution, albeit the protection provided varies depending on the pollutant.35 Mitigation measures must be affordable and broadly applicable to the population, and the level of protection provided should match the risk of population that is being exposed (Figure 2). The latter would necessitate symbicort 160mcg 4.5mcg inhaler price an understanding of the health risk of the patient/community and degree of exposure.
The need and urgency plus intensity of any recommended intervention also need to be weighed against their potential benefits vs. Risks for each individual (e.g. Wasted effort, resources, unnecessary concern, or possible complacency symbicort 160mcg 4.5mcg inhaler price of the user). Although no intervention to reduce air pollution exposure has as yet been shown to reduce cardiovascular events, the consistent link between increased levels of PM2.5 and cardiovascular events, evidence for measures in lowering PM2.5 levels, and the impact of several mitigation strategies in improving surrogate markers are highly suggestive that interventions could be correspondingly impactful in reducing cardiovascular events. Figure 2Mitigation measures to reduce air pollution exposure.Figure 2Mitigation measures symbicort 160mcg 4.5mcg inhaler price to reduce air pollution exposure.Current approaches to mitigate air pollution and their impact have been previously reviewed and can be broadly classified into.
(i) Active personal exposure mitigation with home air cleaning and personal equipment (Table 2). (ii) Modification of human behaviour to reduce passive symbicort 160mcg 4.5mcg inhaler price exposures. (iii) Pharmacologic approaches.32 Studies on N95 respirator under ambient PM2.5 exposure conditions at both high and low levels of exposures over a few hours have shown to reduce systolic blood pressure and improve heart rate variability.32,36 In the only trial comparing exposure mitigation to both noise and air pollution, individual reduction of air pollution or noise with a respirator or noise-cancelling headphones, respectively, did not alter blood pressure. Heart rate variability symbicort 160mcg 4.5mcg inhaler price indices were, however, variably improved with either intervention.37 Face masks and procedural masks (e.g. Surgical masks) are widely available but are not effective in filtering PM2.5, especially if poorly fitting or worn during high activity,38 and therefore cannot be recommended for widespread usage if N95 respirators are available.
Closing car windows, air-conditioning, and cabin air filters represent approaches that could be important in those who are susceptible, but only in those spending large amounts of time in transportation microenvironments. Behavioural strategies such as air pollution avoidance by changing travel routes, staying indoors/closing windows, and modification of symbicort 160mcg 4.5mcg inhaler price activity can help limit air pollution exposure, but unintended consequences in some instances have the potential of offsetting benefit. An example is closing windows to limit outdoor exposure but increasing the hazard for indoor air pollutants or limiting outdoor recreation/exercise to mitigate ambient exposures. The latter symbicort 160mcg 4.5mcg inhaler price scenario of limiting outdoor exposure brings up some very practical questions about the risk/benefit of loss of cardiovascular benefits of exercise vs. Potential gain from benefits secondary to air pollution mitigation.
Health impact modelling and epidemiologic studies have demonstrated that the benefits of aerobic exercise nearly always exceed the risk of air pollution exposure across a range of concentrations, and for long durations of exercise for symbicort 160mcg 4.5mcg inhaler price normal individuals (>75âmin). Based on current evidence, guiding healthy people to avoid outdoor activity in areas with high PM2.5 pollution has the potential to produce greater harm than benefit, given the low absolute risk for cardiovascular or respiratory events. On the other hand, advising patients with pre-established CVD to continue to remain >400âm away from major roadways to avoid exposure to symbicort 160mcg 4.5mcg inhaler price traffic pollutants is a reasonable measure, despite the current lack of strong evidentiary support. Table 2Personal active mitigation methods to reduce air pollution exposure Type of intervention. Efficacy in reducing exposure.
Considerations for symbicort 160mcg 4.5mcg inhaler price use. Evidence in reducing surrogate outcomes. Personal air purifying respirators (reducing solid but not gaseous symbicort 160mcg 4.5mcg inhaler price air pollutants). ÂN95 respirators Highly effective in reducing PM2.5. Removes >95% symbicort 160mcg 4.5mcg inhaler price inhaled particles at 0.3 µm in size Fit and use frequency are key determinants of efficacy.
A valve or microventilator fan may reduce humidity and enhance comfort. Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks Not symbicort 160mcg 4.5mcg inhaler price uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize particles symbicort 160mcg 4.5mcg inhaler price Designed to clean air in a small area.
Effective in reducing indoor particles but duration of use and volume of room, key determinants of efficacy. Efficacy related to clean air delivery rate normalized symbicort 160mcg 4.5mcg inhaler price by room volume, which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure. Effective in reducing symbicort 160mcg 4.5mcg inhaler price concentrations as long as filters replaced regularly. Efficacy is variable with building and operational factors (i.e.
Open windows) No data currently available Type of intervention. Efficacy in symbicort 160mcg 4.5mcg inhaler price reducing exposure. Considerations for use. Evidence in reducing surrogate outcomes symbicort 160mcg 4.5mcg inhaler price. Personal air purifying respirators (reducing solid but not gaseous air pollutants).
ÂN95 respirators Highly symbicort 160mcg 4.5mcg inhaler price effective in reducing PM2.5. Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency are key determinants of efficacy. A valve or microventilator fan may reduce humidity and enhance comfort symbicort 160mcg 4.5mcg inhaler price. Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy.
Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices symbicort 160mcg 4.5mcg inhaler price with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize particles Designed to clean air in a small area. Effective in reducing indoor particles but duration symbicort 160mcg 4.5mcg inhaler price of use and volume of room, key determinants of efficacy. Efficacy related to clean air delivery rate normalized by room volume, which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest symbicort 160mcg 4.5mcg inhaler price a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure.
Effective in reducing concentrations as long as filters replaced regularly. Efficacy is variable with building and operational factors (i.e. Open windows) No data currently available Table 2Personal active mitigation methods symbicort 160mcg 4.5mcg inhaler price to reduce air pollution exposure Type of intervention. Efficacy in reducing exposure. Considerations for symbicort 160mcg 4.5mcg inhaler price use.
Evidence in reducing surrogate outcomes. Personal air purifying respirators (reducing solid but not symbicort 160mcg 4.5mcg inhaler price gaseous air pollutants). ÂN95 respirators Highly effective in reducing PM2.5. Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency symbicort 160mcg 4.5mcg inhaler price are key determinants of efficacy. A valve or microventilator fan may reduce humidity and enhance comfort.
Uncomfortable to wear over long periods Randomized controlled clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks symbicort 160mcg 4.5mcg inhaler price Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters. Electrostatic PACs additionally ionize symbicort 160mcg 4.5mcg inhaler price particles Designed to clean air in a small area. Effective in reducing indoor particles but duration of use and volume of room, key determinants of efficacy.
Efficacy related to clean air delivery rate normalized by room volume, symbicort 160mcg 4.5mcg inhaler price which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure. Effective in reducing concentrations as long as filters replaced regularly. Efficacy is variable with symbicort 160mcg 4.5mcg inhaler price building and operational factors (i.e. Open windows) No data currently available Type of intervention.
Efficacy in symbicort 160mcg 4.5mcg inhaler price reducing exposure. Considerations for use. Evidence in symbicort 160mcg 4.5mcg inhaler price reducing surrogate outcomes. Personal air purifying respirators (reducing solid but not gaseous air pollutants). ÂN95 respirators symbicort 160mcg 4.5mcg inhaler price Highly effective in reducing PM2.5.
Removes >95% inhaled particles at 0.3 µm in size Fit and use frequency are key determinants of efficacy. A valve or microventilator fan may reduce humidity and enhance comfort. Uncomfortable to wear over long periods Randomized controlled symbicort 160mcg 4.5mcg inhaler price clinical trials over short durations (typically up to 48 h) with evidence for reducing blood pressure and improving heart rate variability indices. ÂSurgical and cloth masks Not uniformly effective in reducing PM2.5 exposure While few studies suggest that these may reduce exposure, highly variable in efficacy. Not recommended owing to variability in reducing exposure to particles Portable air cleaners (PAC) âPortable devices with high efficiency-particulate airfilter (HEPA) Filters symbicort 160mcg 4.5mcg inhaler price.
Electrostatic PACs additionally ionize particles Designed to clean air in a small area. Effective in reducing indoor particles but duration of use and volume of room, key determinants symbicort 160mcg 4.5mcg inhaler price of efficacy. Efficacy related to clean air delivery rate normalized by room volume, which must be competitive with ventilation and deposition (loss) rates. Electrostatic PACs may result in ozone production Overall trend in studies suggest a benefit on blood pressure and heart symbicort 160mcg 4.5mcg inhaler price rate variability Heating ventilation and air-conditioning (HVAC) âInstalled centrally in homes with filters that reduce exposure. Effective in reducing concentrations as long as filters replaced regularly.
Efficacy is variable with building and operational factors (i.e. Open windows) No data currently available Although a variety of over the counter drugs and medications have been shown to mitigate association between air pollution and surrogates, almost none can be recommended to protect against symbicort 160mcg 4.5mcg inhaler price air pollution mediated adverse health effects at this time. However, the use of medications for primary and secondary prevention of CHD should be encouraged if indicated for other reasons. Housing and urban design to improve cardiovascular healthTwo-third of the European population live in urban areas and this number continues to grow symbicort 160mcg 4.5mcg inhaler price. A recent Statement on Air Quality Policy has discussed aspects in the built environment that may be targeted in order to reduce exposures to PM2.5 (in press 2020).
Briefly, built environment features may directly or indirectly modify adverse cardiovascular effects of air pollution through the indoor living environment, symbicort 160mcg 4.5mcg inhaler price green spaces, roads, utilities, and transportation infrastructure. The design of communities has the potential of impacting exposures, by affecting the continuum of human existence across indoor living, commuting, working, and recreation (Figure 3). The layout of roads, sidewalks, green spaces, and the availability of cheap public transportation can affect travel behaviour and can help alleviate air quality.39 Communities with proximity and compactness have been associated with higher life expectancy, improved air quality, and health.40,41 Green environments can improve air quality, encourage physical activity, and promote social interactions, ultimately improving cardiovascular health. Indeed, there is evidence symbicort 160mcg 4.5mcg inhaler price to support a protective association of green spaces on PM-associated CVD.42,43All-cause and ischaemic heart disease mortality related to income deprivation has been shown to be lower in populations who live in the greenest areas, vs. Those who have less exposure to green space.44 Recently, Giles-Corti identified eight integrated regional and local interventions that, when combined, encourage walking, cycling and public transport use, while reducing private motor vehicle use.45 These eight interventions are directed to reduce traffic exposure, to reduce air pollution and noise, and to reduce the important public health issue loneliness and social isolation, to improve the safety from crime, to reduce physical inactivity and prolonged sitting, and to prevent the consumption of unhealthy diets.45 Figure 3Urban design considerations to reduce exposure to noise and air pollution.Figure 3Urban design considerations to reduce exposure to noise and air pollution.
Take home figureUpper left panel reproduced from Münzel symbicort 160mcg 4.5mcg inhaler price et al.46 with permission.Take home figureUpper left panel reproduced from Münzel et al.46 with permission. Future perspectives. Opportunities and challenges over the next decadeEfforts to mitigate air pollution and noise are endeavours that involve complex economic and geopolitical considerations symbicort 160mcg 4.5mcg inhaler price. Measures such as transportation reform, shift to zero-emission fuels, urban landscape reform, and ecologically sound lifestyle changes may help simultaneously alleviate air/noise pollution while accomplishing climate change goals. However, reducing air pollution and noise may have short-term symbicort 160mcg 4.5mcg inhaler price challenges due to economic incentives that are substantially misaligned with health and environmental priorities and thus opportunities to understand the importance of these factors in human health will sadly continue.
An important avenue of investigation is convergent studies that look at the broad and collective impact and burden of air and noise pollution as archetypal environmental risk factors. The questions that need to be addressed are many and include the magnitude and time course of response of co-exposure, interactive effects of environmental factors on surrogate measures, duration of effect/time course of reversal, impact on circadian rhythm, and finally the effect of reversal as well as prevention and lifestyle approaches that may help mitigate risk (e.g. Diet, stress, and exercise).The rapid development of personalized technologies that symbicort 160mcg 4.5mcg inhaler price provide multiple measures of health in fine temporal detail in conjunction with data on environmental exposure provide an unprecedented opportunity for research and may allow an extraordinary understanding of the interactions between environmental and non-environmental risk factors over long durations. Together with developments in next-generation sequencing technologies, and opportunities in big data, assimilative studies of this nature may finally provide a granular view of the environmentalâgenetic interactions leading to the development of CVD. However, the extent of these advances may be tempered by the need to manage subject burden and symbicort 160mcg 4.5mcg inhaler price costs, and imprecise data on many environmental variables.
Increased awareness of the societal burden posed by environmental risk factors and acknowledgement in traditional risk factor guidelines may pressurize politicians to intensify the efforts required for effective legislation.The cardiovascular community has a responsibility to help promulgate the impact of, not only health lifestyle and diet, but also over the outsize impact of air and noise pollution on cardiovascular health. Individuals can apply political pressure through democratic means and lobbying to enact changes at symbicort 160mcg 4.5mcg inhaler price regional and national levels that lead to reductions in noise/air pollution exposure. Patient organization can provide a strong voice in the call for action at governmental level. Importantly, air pollution was mentioned in the symbicort 160mcg 4.5mcg inhaler price published guidelines for cardiovascular prevention, but the recommendations to reduce pollution were completely insufficient,47 while prevention measures with respect to traffic noise were completely lacking. Noise and air pollution represent significant cardiovascular risk factors, it is important that these factors are included into the ESC guidelines, and others, for myocardial infarction, arterial hypertension, and heart failure.
AcknowledgementsWe are indebted to the expert graphical assistance of Margot Neuser. FundingA.D. And T.M. Were supported by vascular biology research grants from the Boehringer Ingelheim Foundation for the collaborative research group âNovel and neglected cardiovascular risk factors. Molecular mechanisms and therapeuticsâ with continuous research support from Foundation Heart of Mainz.
T.M. Is PI of the DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany. M.R.M. Is supported by the British Heart Foundation (CH/09/002). S.R.
Was supported in part by the National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH) under Award Numbers U01ES026721 and 5R01ES019616-07 and 1R01ES026291.Conflict of interest. None declared. References1Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu NN, Balde AB, Bertollini R, Bose-O'Reilly S, Boufford JI, Breysse PN, Chiles T, Mahidol C, Coll-Seck AM, Cropper ML, Fobil J, Fuster V, Greenstone M, Haines A, Hanrahan D, Hunter D, Khare M, Krupnick A, Lanphear B, Lohani B, Martin K, Mathiasen KV, McTeer MA, Murray CJL, Ndahimananjara JD, Perera F, Potocnik J, Preker AS, Ramesh J, Rockstrom J, Salinas C, Samson LD, Sandilya K, Sly PD, Smith KR, Steiner A, Stewart RB, Suk WA, van Schayck OCP, Yadama GN, Yumkella K, Zhong M. The Lancet Commission on pollution and health. Lancet 2018;391:462â512.2Aronow WS.
Drug treatment of elderly patients with acute myocardial infarction. Practical recommendations. Drugs Aging 2001;18:807â818.3Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, Balakrishnan K, Brunekreef B, Dandona L, Dandona R, Feigin V, Freedman G, Hubbell B, Jobling A, Kan H, Knibbs L, Liu Y, Martin R, Morawska L, Pope CA3rd, Shin H, Straif K, Shaddick G, Thomas M, van Dingenen R, van Donkelaar A, Vos T, Murray CJL, Forouzanfar MH. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution. An analysis of data from the Global Burden of Diseases Study 2015.
Lancet 2017;389:1907â1918.4Hirose R, Okumura H, Yoshimatsu A, Irie J, Onoda Y, Nomoto Y, Takai H, Ohno T, Ichimura M. KF31327, a new potent and selective inhibitor of cyclic nucleotide phosphodiesterase 5. Eur J Pharmacol 2001;431:17â24.5Burnett R, Chen H, Szyszkowicz M, Fann N, Hubbell B, Pope CA3rd, Apte JS, Brauer M, Cohen A, Weichenthal S, Coggins J, Di Q, Brunekreef B, Frostad J, Lim SS, Kan H, Walker KD, Thurston GD, Hayes RB, Lim CC, Turner MC, Jerrett M, Krewski D, Gapstur SM, Diver WR, Ostro B, Goldberg D, Crouse DL, Martin RV, Peters P, Pinault L, Tjepkema M, van Donkelaar A, Villeneuve PJ, Miller AB, Yin P, Zhou M, Wang L, Janssen NAH, Marra M, Atkinson RW, Tsang H, Quoc Thach T, Cannon JB, Allen RT, Hart JE, Laden F, Cesaroni G, Forastiere F, Weinmayr G, Jaensch A, Nagel G, Concin H, Spadaro JV. Global estimates of mortality associated with long-term exposure to outdoor fine particulate matter. Proc Natl Acad Sci U S A 2018;115:9592â9597.6Lelieveld J, Pozzer A, Poschl U, Fnais M, Haines A, Munzel T, Loss of life expectancy from air pollution compared to other risk factors.
A worldwide perspective. Cardiovasc Res 2020;116:1910â1917.7Lelieveld J, Munzel T. Air pollution, chronic smoking, and mortality. Eur Heart J 2019;40:3204.8Kalsch H, Hennig F, Moebus S, Mohlenkamp S, Dragano N, Jakobs H, Memmesheimer M, Erbel R, Jockel K-H, Hoffmann B, Roggenbuck U, Slomiany U, Beck EM, Offner A, Munkel S, Schrader S, Peter R, Hirche H, Meinertz T, Bode C, deFeyter PJ, Guntert B, Halli T, Gutzwiller F, Heinen H, Hess O, Klein B, Lowel H, Reiser M, Schmidt G, Schwaiger M, Steinmuller C, Theorell T, Willich SN. On behalf of the Heinz Nixdorf Recall Study Investigative Group.
Are air pollution and traffic noise independently associated with atherosclerosis. The Heinz Nixdorf Recall Study. Eur Heart J 2014;35:853â860.9Brown AL, Lam KC, van Kamp I. Quantification of the exposure and effects of road traffic noise in a dense Asian city. A comparison with western cities.
Environ Health 2015;14:22.11Kempen EV, Casas M, Pershagen G, Foraster M. WHO environmental noise guidelines for the European region. A systematic review on environmental noise and cardiovascular and metabolic effects. A summary. Int J Environ Res Public Health 2018;15:379.12Seidler AL, Hegewald J, Schubert M, Weihofen VM, Wagner M, Droge P, Swart E, Zeeb H, Seidler A.
The effect of aircraft, road, and railway traffic noise on strokeâresults of a case-control study based on secondary data. Noise Health 2018;20:152â161.13Halonen JI, Hansell AL, Gulliver J, Morley D, Blangiardo M, Fecht D, Toledano MB, Beevers SD, Anderson HR, Kelly FJ, Tonne C. Road traffic noise is associated with increased cardiovascular morbidity and mortality and all-cause mortality in London. Eur Heart J 2015;36:2653â2661.14Héritier H, Vienneau D, Foraster M, Eze IC, Schaffner E, Thiesse L, Rudzik F, Habermacher M, Köpfli M, Pieren R, Brink M, Cajochen C, Wunderli JM, Probst-Hensch N, Röösli M. SNC Study Group.
Transportation noise exposure and cardiovascular mortality. A nationwide cohort study from Switzerland. Eur J Epidemiol 2017;32:307â315.15Cai Y, Hodgson S, Blangiardo M, Gulliver J, Morley D, Fecht D, Vienneau D, de Hoogh K, Key T, Hveem K, Elliott P, Hansell AL. Road traffic noise, air pollution and incident cardiovascular disease. A joint analysis of the HUNT, EPIC-Oxford and UK Biobank cohorts.
Environ Int 2018;114:191â201.16Monrad M, Sajadieh A, Christensen JS, Ketzel M, Raaschou-Nielsen O, Tjønneland A, Overvad K, Loft S, Sørensen M. Residential exposure to traffic noise and risk of incident atrial fibrillation. A cohort study. Environ Int 2016;92â93:457â463.17Hansell AL, Blangiardo M, Fortunato L, Floud S, de HK, Fecht D, Ghosh RE, Laszlo HE, Pearson C, Beale L, Beevers S, Gulliver J, Best N, Richardson S, Elliott P. Aircraft noise and cardiovascular disease near Heathrow airport in London.
Small area study. BMJ 2013;347:f5432.18Kempen EV, Casas M, Pershagen G, Foraster M. WHO environmental noise guidelines for the European region. A systematic review on environmental noise and cardiovascular and metabolic effects. A summary.
Int J Environ Res Public Health 2018;15:379.19Zare Sakhvidi MJ, Zare Sakhvidi F, Mehrparvar AH, Foraster M, Dadvand P. Association between noise exposure and diabetes. A systematic review and meta-analysis. Environ Res 2018;166:647â657.20Pyko A, Eriksson C, Lind T, Mitkovskaya N, Wallas A, Ogren M, Ostenson CG, Pershagen G. Long-term exposure to transportation noise in relation to development of obesityâa cohort study.
Environ Health Perspect 2017;125:117005.21Thacher JD, Hvidtfeldt UA, Poulsen AH, Raaschou-Nielsen O, Ketzel M, Brandt J, Jensen SS, Overvad K, Tjønneland A, Münzel T, Sørensen M. Long-term residential road traffic noise and mortality in a Danish cohort. Environ Res 2020;187:109633.22Eriksson HP, Andersson E, Schioler L, Soderberg M, Sjostrom M, Rosengren A, Toren K. Longitudinal study of occupational noise exposure and joint effects with job strain and risk for coronary heart disease and stroke in Swedish men. BMJ Open 2018;8:e019160.23Stokholm ZA, Bonde JP, Christensen KL, Hansen AM, Kolstad HA.
Occupational noise exposure and the risk of stroke. Stroke 2013;44:3214â3216.24Babisch W. The noise/stress concept, risk assessment and research needs. Noise Health 2002;4:1â11.25Munzel T, Sorensen M, Gori T, Schmidt FP, Rao X, Brook FR, Chen LC, Brook RD, Rajagopalan S. Environmental stressors and cardio-metabolic disease.
Part II-mechanistic insights. Eur Heart J 2016;38:557â564.26Hahad O, Prochaska JH, Daiber A, Münzel T. Environmental noise-induced effects on stress hormones, oxidative stress, and vascular dysfunction. Key factors in the relationship between cerebrocardiovascular and psychological disorders. Oxid Med Cell Longev 2019;2019:1â13.27Osborne MT, Radfar A, Hassan MZO, Abohashem S, Oberfeld B, Patrich T, Tung B, Wang Y, Ishai A, Scott JA, Shin LM, Fayad ZA, Koenen KC, Rajagopalan S, Pitman RK, Tawakol A.
A neurobiological mechanism linking transportation noise to cardiovascular disease in humans. Eur Heart J 2020;41:772â782.28Münzel T, Daiber A, Steven S, Tran LP, Ullmann E, Kossmann S, Schmidt FP, Oelze M, Xia N, Li H, Pinto A, Wild P, Pies K, Schmidt ER, Rapp S, Kröller-Schön S. Effects of noise on vascular function, oxidative stress, and inflammation. Mechanistic insight from studies in mice. Eur Heart J 2017;38:2838â2849.29Kröller-Schön S, Daiber A, Steven S, Oelze M, Frenis K, Kalinovic S, Heimann A, Schmidt FP, Pinto A, Kvandova M, Vujacic-Mirski K, Filippou K, Dudek M, Bosmann M, Klein M, Bopp T, Hahad O, Wild PS, Frauenknecht K, Methner A, Schmidt ER, Rapp S, Mollnau H, Münzel T.
Crucial role for Nox2 and sleep deprivation in aircraft noise-induced vascular and cerebral oxidative stress, inflammation, and gene regulation. Eur Heart J 2018;39:3528â3539.30Herzog J, Schmidt FP, Hahad O, Mahmoudpour SH, Mangold AK, Garcia Andreo P, Prochaska J, Koeck T, Wild PS, Sørensen M, Daiber A, Münzel T. Acute exposure to nocturnal train noise induces endothelial dysfunction and pro-thromboinflammatory changes of the plasma proteome in healthy subjects. Basic Res Cardiol 2019;114:46.31Brook RD, Rajagopalan S, Pope CA3rd, Brook JR, Bhatnagar A, Diez-Roux AV, Holguin F, Hong Y, Luepker RV, Mittleman MA, Peters A, Siscovick D, Smith SCJr, Whitsel L, Kaufman JD, American Heart Association Council on Epidemiology and Prevention, Council on the Kidney in Cardiovascular Disease, and Council on Nutrition, Physical Activity and Metabolism. Particulate matter air pollution and cardiovascular disease.
An update to the scientific statement from the American Heart Association. Circulation 2010;121:2331â2378.32Al-Kindi S, Brook RD, Biswal S, Rajagopalan S. Environmental determinants of cardiovascular disease. Lessons learned from air pollution. Nat Rev Cardiol 2020;17:656â672.33Lelieveld J, Klingmuller K, Pozzer A, Poschl U, Fnais M, Daiber A, Munzel T.
Cardiovascular disease burden from ambient air pollution in Europe reassessed using novel hazard ratio functions. Eur Heart J 2019;40:1590â1596.34Miller MR, Newby DE. Air pollution and cardiovascular disease. Car sick. Cardiovasc Res 2020;116:279â294.35Rajagopalan S, Huang S, Brook RD.
Flattening the curve in anti inflammatory drugs using personalised protective equipment. Lessons from air pollution. Heart 2020;106:1286â1288.36Langrish JP, Li X, Wang S, Lee MM, Barnes GD, Miller MR, Cassee FR, Boon NA, Donaldson K, Li J, Li L, Mills NL, Newby DE, Jiang L. Reducing personal exposure to particulate air pollution improves cardiovascular health in patients with coronary heart disease. Environ Health Perspect 2012;120:367â372.37Yang X, Jia X, Dong W, Wu S, Miller MR, Hu D, Li H, Pan L, Deng F, Guo X.
Cardiovascular benefits of reducing personal exposure to traffic-related noise and particulate air pollution. A randomized crossover study in the Beijing subway system. Indoor Air 2018;28:777â786.38Cherrie JW, Apsley A, Cowie H, Steinle S, Mueller W, Lin C, Horwell CJ, Sleeuwenhoek A, Loh M. Effectiveness of face masks used to protect Beijing residents against particulate air pollution. Occup Environ Med 2018;75:446â452.39United States Department of Environmental Protection.
Our Built and Natural Environments. A Technical Review of the Interactions Among Land Use, Transportation, and Environmental Quality. 2013. U.S. Environmental Protection Agency, Washington, USA.40Hamidi S, Ewing R, Tatalovich Z, Grace JB, Berrigan D.
Associations between Urban Sprawl and Life Expectancy in the United States. Int J Environ Res Public Health 2018;15:861.41Hankey S, Marshall JD. Urban form, air pollution, and health. Curr Environ Health Rep 2017;4:491â503.42Heo S, Bell ML. The influence of green space on the short-term effects of particulate matter on hospitalization in the U.S.
For 2000â2013. Environ Res 2019;174:61â68.43Yitshak-Sade M, James P, Kloog I, Hart JE, Schwartz JD, Laden F, Lane KJ, Fabian MP, Fong KC, Zanobetti A. Neighborhood greenness attenuates the adverse effect of PM2.5 on cardiovascular mortality in neighborhoods of lower socioeconomic status. Int J Environ Res Public Health 2019;16:814.44Mitchell R, Popham F. Effect of exposure to natural environment on health inequalities.
An observational population study. Lancet 2008;372:1655â1660.45Giles-Corti B, Vernez-Moudon A, Reis R, Turrell G, Dannenberg AL, Badland H, Foster S, Lowe M, Sallis JF, Stevenson M, Owen N. City planning and population health. A global challenge. Lancet 2016;388:2912â2924.46Münzel T, Steven S, Frenis K, Lelieveld J, Hahad O, Daiber A.
Environmental factors such as Noise and Air Pollution and Vascular Disease. Antioxid Redox Signal 2020;33:581â601.47Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Lochen ML, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S. ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention &.
Rehabilitation (EACPR). Eur Heart J 2016;37:2315â2381. Author notes© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com.
ÂFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This how to buy symbicort online is a Focus Issue on valvular heart disease (VHD), which is progressively occupying the centre stage of cardiovascular medicine. Changing societal demographics and an ageing population (with increasing prevalence of degenerative disease), advances in imaging, and the explosion of interest in transcatheter interventional techniques (supported by a series of landmark clinical trials) have attracted clinicians, researchers, engineers, device manufacturers, and investors, and transformed the landscape of clinical management.1â4The first contribution is a clinical research article entitled âIsolated tricuspid valve surgery. Impact of aetiology and clinical presentation on outcomesâ, by Julien how to buy symbicort online Dreyfus from the Centre Cardiologique du Nord in Saint-Denis, France, and colleagues. The authors sought to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery as little is known regarding the impact of tricuspid regurgitation (TR), its mechanism, and clinical presentation.5 Among â¼5600 consecutive adult patients who underwent tricuspid valve surgery at 12 French tertiary centres in 2007â2017 collected from a mandatory administrative database, the authors identified 466 patients who underwent an isolated tricuspid valve surgery.
Most patients presented with advanced disease [47% in New York Heart Association (NYHA) class III/IV, 57% with right-sided heart failure signs]. TR was functional in 49% (22% with prior left-sided heart valve how to buy symbicort online surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%). In-hospital mortality and major complication rates were 10% and 31%, respectively. Rates of survival and survival free of how to buy symbicort online heart failure readmission were 75% and 62% at 5 years.
Independent determinants of outcomes were NYHA class III/IV [odds ratio (OR) 2.7], moderate/severe right ventricular dysfunction (OR 2.6), and lower prothrombin time (OR 0.9), while the mechanism of TR was not associated with the outcomes.The authors conclude that isolated tricuspid valve surgery is associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by the mechanism of TR. The results suggest that tricuspid valve interventions should be performed earlier in the course of the disease. The manuscript is accompanied by an Editorial by Victoria Delgado from the Leiden University Medical Center in the Netherlands and colleagues.6 The authors note that while data on the efficacy and durability of current transcatheter therapies are awaited, granular data such as those reported in the present article by Dreyfus et al.5 are important to highlight the need for early referral for isolated how to buy symbicort online tricuspid valve intervention in patients with severe TR.Mitral annular calcification (MAC) is a common degenerative mitral valve disease characterized by calcification at the level of the mitral annulus that can be associated with significant mitral valve dysfunction including both stenosis and regurgitation. MAC is associated with female sex, advanced age, chronic kidney disease, and multiple cardiovascular risk factors, and prevalence ranges from 8% to 15% in the general population and reaches as high as 40% among the elderly.
In a clinical research manuscript entitled âPrognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunctionâ, Philippe Bertrand from the Massachusetts General Hospital in Massachusetts, USA, and colleagues sought to define the natural history of patients with MAC-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient and impact of concomitant mitral regurgitation (MR).7 The institutional echocardiography database was examined for the period 2001â2019 for all patients with MAC and mean gradient (MG) â¥3 mmHg. About 5700 patients were stratified by MG how to buy symbicort online into low (3â5 mmHg), mid (5â10 mmHg), and high (â¥10 mmHg) gradient. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, and chronic kidney disease). Mean transmitral pressure gradient was independently how to buy symbicort online associated with mortality [adjusted hazard ratio (HR) 1.064 per 1 mmHg increase).
MR severity was associated with mortality at low gradients but not at higher gradients.Bertrand and colleagues conclude that in MAC-related mitral valve dysfunction, mean transmitral gradient is associated with increased mortality after adjustment for age, sex, and MAC-related risk factors. Concomitant MR is associated with excess mortality in low gradient ranges but gradually loses prognostic importance at higher gradients, indicating prognostic utility of the transmitral gradient in MAC regardless of MR severity. The manuscript is accompanied by an Editorial by Rebecca Hahn from Columbia University in New York, USA.8 who notes that any echocardiographic evidence for annular calcification may be an indication to use advanced multimodality imaging and novel biomarkers since these new tools may be the key to unlocking the mystery of intracardiac calcification and allow early how to buy symbicort online detection and disease prevention.Cardiac myxomas usually develop in the atria and consist of an acid mucopolysaccharide-rich myxoid matrix with polygonal stromal cells scattered throughout. These human benign tumours are a valuable research model because of the rarity of cardiac tumours, their clinical presentation, and uncertain origin.
In a Translational Research article entitled âAtrial myxomas arise from multipotent cardiac stem cellsâ, Mariangela Scalise from the Magna Graecia University in Catanzaro, Italy, and colleagues assessed whether human adult cardiac stem cells give rise to myxoma stromal cells.9 The authors collected and analysed 23 myxomas for the presence of multipotent cardiac stem cells. They detected how to buy symbicort online myxoma cells positive for c-kit. Most of the c-kit-positive cells were blood lineage-committed cells. However, blood lineage-uncommitted c-kit-positive how to buy symbicort online cardiac myxoma cells expressed stemness and cardiac progenitor cell transcription factors.
Approximately 10% of the blood lineage-uncommitted c-kit-positive cardiac myxoma cells expressed calretinin, a characteristic of myxoma stromal cells. In vitro, blood lineage-uncommitted c-kit-positive cardiac myxoma cells secreted chondroitin-6-sulfate and hyaluronic acid, which are the main components of the gelatinous myxoma matrix in vivo, and showed clonogenic, self-renewing, and sphere-forming properties (Figure 1). Figure 1The main findings of the study showing that cardiac myxomas arise from multipotent c-kitpos/CD45neg/CD31neg myxoma tumour initiating cells and the working hypothesis of their direct derivation from normal c-kitpos/CD45neg/CD31neg cardiac stem/progenitor cells transformed by specific miRNA modulation (from Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza C, Cianflone E, Mancuso T, Aquila I, Salerno L, Nassa G, Agosti V, De Angelis A, how to buy symbicort online Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto P, De Feo M, Viglietto G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells.
See pages 4332â4345).Figure 1The main findings of the study showing that cardiac myxomas arise from multipotent c-kitpos/CD45neg/CD31neg myxoma tumour initiating cells and the working hypothesis of their direct derivation from normal c-kitpos/CD45neg/CD31neg cardiac stem/progenitor cells transformed by specific miRNA modulation (from Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza C, Cianflone E, Mancuso T, Aquila I, Salerno L, Nassa G, Agosti V, De Angelis A, Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto P, De Feo M, Viglietto how to buy symbicort online G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells. See pages 4332â4345).The authors conclude that human myxoma is the first described cardiac stem cell-related human cardiac disease. This manuscript how to buy symbicort online is accompanied by an Editorial by Mark Alan Sussman from the San Diego State University in California, USA10 who notes that Scalise et al.
Reveal the fundamental contribution of cardiac stem cells to atrial myxomas, offering provocative and tantalizing new insights for myocardial biology as well as strategic approaches to translational applications.Management of VHD has dramatically changed over the last few decades. The primary goal has moved away from relieving symptoms once they occur to optimizing long-term morbidity and mortality, which requires timely intervention. Early symptoms (the start of a how to buy symbicort online decline in exercise capacity/exertional shortness of breath) are a clear trigger for intervention, but even asymptomatic patients may be at risk when followed conservatively.11,12 The issue contains a State of the Art review article entitled âTiming of intervention in asymptomatic patients with valvular heart diseaseâ by Helmut Baumgartner from the University Hospital Muenster in Germany, and colleagues. The authors note that recommendations for treatment of patients with symptoms due to severe valvular disease are based on a foundation of solid evidence.4 However, when to intervene in asymptomatic patients remains controversial, and decision requires careful individual weighing of the potential benefits against the risk of intervention and its long-term consequences.
The primary rationale for earlier intervention is prevention of irreversible left ventricular (LV) myocardial changes that might result in later clinical symptoms and adverse how to buy symbicort online cardiac events. Various outcome predictors have been identified that facilitate decision-making. This review summarizes current recommendations and discusses recently published data that challenge them suggesting even earlier intervention. In adults with asymptomatic aortic stenosis, emerging risk markers include very severe how to buy symbicort online valve obstruction, elevated serum natriuretic peptide levels, and imaging evidence of myocardial fibrosis or increased extracellular myocardial volume.
Currently, transcatheter aortic valve implantation (TAVI) is not recommended for treatment of asymptomatic severe aortic stenosis although this may change in the future. In patients with aortic regurgitation, the potential benefit of early intervention in preventing LV dilation and dysfunction must be balanced against the long-term risk of a prosthetic valve, a particular concern because severe aortic regurgitation often occurs in younger patients with a congenital bicuspid valve. In patients with mitral stenosis, the option of transcatheter mitral balloon how to buy symbicort online valvotomy tilts the balance towards earlier intervention to prevent atrial fibrillation, embolic events, and pulmonary hypertension. When chronic severe MR is due to mitral valve prolapse, anatomic features consistent with a high likelihood of a successful and durable valve repair favour early intervention.
The authors conclude that optimal timing of intervention how to buy symbicort online in adults with VHD is a constantly changing threshold that depends not only on the severity of valve disease but on the safety, efficacy, and long-term durability of our treatment options (Figure 2). Figure 2Weighing of risks and benefits of intervention in asymptomatic valvular heart disease. Aspects that need to be considered and key questions for decision-making. Arrhyth., arrhythmias how to buy symbicort online.
GL, guidelines. HF, heart failure. Interv., intervention how to buy symbicort online. LA, left atrium.
LV, left how to buy symbicort online ventricle. Pulm., pulmonary. VHD, valvular heat disease (from Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart how to buy symbicort online disease.
See pages 4349â4356).Figure 2Weighing of risks and benefits of intervention in asymptomatic valvular heart disease. Aspects that how to buy symbicort online need to be considered and key questions for decision-making. Arrhyth., arrhythmias. GL, guidelines.
HF, heart how to buy symbicort online failure. Interv., intervention. LA, left atrium. LV, left ventricle how to buy symbicort online.
Pulm., pulmonary. VHD, valvular heat disease (from Baumgartner H, how to buy symbicort online Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease. See pages 4349â4356).The issue is also complemented by Discussion Forum contributions.
In a contribution entitled âIs the national how to buy symbicort online readmission database the right database to identify valve-in-valve transcatheter aortic valve replacement patients?. Â, Salik Nazir from the University of Toledo in Toledo, Ohio, USA comment on the recent publication âComparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs. Reoperative surgical aortic valve replacement. A contemporary assessment of real-world outcomesâ by Sameer A how to buy symbicort online Hirji from Harvard Medical School in Boston, Massachusetts, USA, and colleagues.13,14 Hirji et al.
Respond in a separate comment.15In a contribution entitled âVariable rate of stroke after transcatheter aortic valve replacement with self-expandable valves. More doubts than certaintiesâ, Marco Ferlini from the Policlinico San Matteo in Pavia, Italy comment how to buy symbicort online on the recent article âComparison of newer generation self-expandable vs. Balloon-expandable valves in transcatheter aortic valve implantation. The randomized SOLVE-TAVI trialâ.16,17 Thiele et al.
Respond in a separate comment.18The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to how to buy symbicort online Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart how to buy symbicort online J 2017;38:2739â2791.2Binder RK, Dweck M, Prendergast B.
The year in cardiology. Valvular heart how to buy symbicort online disease. Eur Heart J 2020;41:912â920.3Lüscher TF. Valvular heart disease.
Improved procedural success how to buy symbicort online and prediction of outcomes. Eur Heart J 2020;41:899â902.4Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease how to buy symbicort online. Eur Heart J 2020;41:4349â4356.5Dreyfus J, Flagiello M, Bazire B, Eggenspieler F, Viau F, Riant E, Mbaki Y, Bohbot Y, Eyharts D, Senage T, Dubrulle H, Nicol M, Doguet F, Nguyen V, Coisne A, Le Tourneau T, Lavie-Badie Y, Tribouilloy C, Donal E, Tomasi J, Habib G, Selton-Suty C, Raffoul R, Iung B, Obadia JF, Messika-Zeitoun D.
Isolated tricuspid valve surgery. Impact of aetiology and clinical how to buy symbicort online presentation on outcomes. Eur Heart J 2020;41:4304â4317.6Delgado V, Ajmone Marsan N, Bax JJ. The difficult decision of when and in whom to perform isolated tricuspid valve surgery.
Eur Heart J how to buy symbicort online 2020;41:4318â4320.7Bertrand, PB, Churchill, TW, Yucel, E, Namasivayam, M, Bernard, S, Nagata, Y, He, W, Andrews, CT, Picard, MH, Weyman, AE, Levine, RA and Hung, J. Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction. Eur Heart J 2020;41:4321â4328.8Hahn RT how to buy symbicort online. Degenerative mitral stenosis.
Interpreting the meaning of mean gradient. Eur Heart J 2020;41:4329â4331.9Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza C, Cianflone E, Mancuso T, Aquila I, Salerno L, Nassa G, Agosti V, De Angelis A, Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto how to buy symbicort online P, De Feo M, Viglietto G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells. Eur Heart J 2020;41:4332â4345.10Sussman MA.
Atrial myxoma how to buy symbicort online. The cardiac chameleon. Eur Heart how to buy symbicort online J 2020;41:4346â4348.11Pellikka PA. Predicting outcome in asymptomatic aortic stenosis.
Should we measure the severity of obstruction or its physiological consequences?. Eur Heart J 2010;31:2191â2193.12Singh A, Greenwood JP, Berry C, Dawson DK, Hogrefe K, Kelly DJ, Dhakshinamurthy V, Lang CC, Khoo JP, Sprigings D, Steeds RP, Jerosch-Herold M, Neubauer S, Prendergast B, Williams how to buy symbicort online B, Zhang R, Hudson I, Squire IB, Ford I, Samani NJ, McCann GP. Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis. The PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) Study.
Eur Heart J 2017;38:1222â1229.13Nazir S, how to buy symbicort online Ahuja KR, Alamir MA. Is the national readmission database the right database to identify valve-in-valve transcatheter aortic valve replacement patients?. Eur Heart how to buy symbicort online J 2020;41:4357.14Hirji SA, Percy ED, Zogg CK, Malarczyk A, Harloff MT, Yazdchi F, Kaneko T. Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs.
Reoperative surgical aortic valve replacement. A contemporary assessment of how to buy symbicort online real-world outcomes. Eur Heart J 2020;41:2747â2755.15Hirji S, Zogg CK, Kaneko T. The utility of the nationwide readmissions database in understanding contemporary transcatheter aortic valve replacement outcomes how to buy symbicort online.
Eur Heart J 2020;41:4358â4359.16Ferlini M, Mauri S. Variable rate of stroke after transcatheter aortic valve replacement with self-expandable valves. More doubts than how to buy symbicort online certainties. Eur Heart J 2020;41:4360â4361.17Thiele H, Kurz T, Feistritzer HJ, Stachel G, Hartung P, Eitel I, Marquetand C, Nef H, Doerr O, Lauten A, Landmesser U, Abdel-Wahab M, Sandri M, Holzhey D, Borger M, Ince H, Ãner A, Meyer-Saraei R, Wienbergen H, Fach A, Frey N, König IR, Vonthein R, Rückert Y, Funkat AK, de Waha-Thiele S, Desch S.
Comparison of newer generation self-expandable vs. Balloon-expandable valves in transcatheter aortic valve how to buy symbicort online implantation. The randomized SOLVE-TAVI trial. Eur Heart J 2020;41:1890â1899.18Thiele H, Abdel-Wahab M, how to buy symbicort online Desch S.
Stroke rates after transcatheter aortic valve replacement. Does valve choice play a role?. Eur how to buy symbicort online Heart J 2020;41:4362. Published on behalf of the European Society of Cardiology.
All rights reserved. © The how to buy symbicort online Author(s) 2020. For permissions, please email. Journals.permissions@oup.com.âVi-R(e)alâ Learning how to buy symbicort online Methods.
Opportunity amidst adversityâLearn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expertââââââââââââââââââââââââââââââââââââââââSir William OslerCardiology training in most parts of the world involves rotations in the outpatient department, inpatient services, non-invasive imaging laboratories, and cardiac catheterization laboratories with or without dedicated research time based on each programme and individual.1â4 As per the World Health Organization, anti inflammatory drugs has been a symbicort since 11 March 2020.5 In most places, specialists and trainees of different specialties have started managing patients with anti inflammatory drugs, as it was and still is the need of the hour globally. As a consequence, Cardiology Fellows across the world have had a significant impact on their training,6 teaching and procedural volumes. The Department of Cardiology at SRIHER,7 Chennai, India has observed this deficiency and how to buy symbicort online made substantial changes to our curriculum focusing on virtual meetings starting from the end of March 2020. Virtual meetings included journal clubs, seminars, technical aspects of procedures, and clinical case presentations.
Although most of the topics were informative and educational, the virtual case presentations were perceived to be the most interesting. Initially, it was how to buy symbicort online conducted by our own faculties to our departmental Fellows. Later, we realized that such virtual case presentations would be the ânew normalâ during this anti inflammatory drugs symbicort for all the Fellows in the country. This encouraged us to conduct the same as an e-course for the benefit of the fellows.Currently, how to buy symbicort online we are undertaking a series of virtual case presentations, which are being chaired by eminent faculties from several institutes of national importance in India.
Though there is no parallel to bedside teaching, these virtual case presentations and lectures conducted by distinguished faculties across the country brought a significant impact on the education of our fellows. We believe that an involvement from major societies across the globe in these types of activities that are focused on future leaders is paramount importance. We have how to buy symbicort online described in brief the advantages and disadvantages of the virtual learning series in Table 1. Table 1Advantages and disadvantages of âVi-R(e)alâ learning methods Advantages.
Disadvantages how to buy symbicort online. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Advantages. Disadvantages. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Table 1Advantages and disadvantages of how to buy symbicort online âVi-R(e)alâ learning methods Advantages.
Disadvantages. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Advantages. Disadvantages. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue As Sir Osler rightly said, âThe very first step towards the success of any occupation is to become interested in itâ.
We see Fellows taking interest in attending such virtual case presentations where they gain knowledge from different groups of faculties, which widens their horizons.This anti inflammatory drugs symbicort enabled us to search for opportunities amidst adversity that inspired such virtual case presentations and drove us to adapt by using e-simulation techniques to help surgical or intervention-oriented fields. We feel that while the virtual teaching sessions can never replace Oslerâs method of bedside learning, they will strengthen its value by complementing it in real-time, leading to a new-era of teaching which we call âVi-R(e)alâ learning methods. We define âVi-R(e)alâ learning methods as a futuristic learning tool where e-forums, courses, and simulations will be taught by national and international experts. We believe that such a method will improve training globally and aid in serving humanity better.
We also believe that âVi-R(e)alâ learning methods could soon become the norm for the future, to increase knowledge base and decrease disparities in training between different centres.âThe learned make each land their own, in every city find a home;Who, till they die. Learn nought, along what weary ways they roam!. ÂAs expressed in the above translated couplet from the Thirukkural,8 which was written over 2000 years ago by the acclaimed Tamil poet Thiruvalluvar, wherein he pondered that education would open a gateway to the world and in true sense we are living that vision today by uniting global education through web-based platforms.Conflict of interest. None declared.
ReferencesReferences are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020.
For permissions, please email. Journals.permissions@oup.com..
ÂFor the symbicort 160mcg 4.5mcg inhaler price podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This is a Focus Issue on valvular heart disease (VHD), which is progressively occupying the centre stage of cardiovascular medicine. Changing societal demographics and an ageing population (with increasing prevalence of degenerative disease), advances in imaging, and the explosion of interest in transcatheter interventional techniques (supported by a series of landmark clinical trials) have attracted clinicians, researchers, engineers, device manufacturers, and investors, and transformed the landscape of clinical management.1â4The first contribution is a clinical research article entitled âIsolated tricuspid valve surgery. Impact of aetiology and clinical presentation symbicort 160mcg 4.5mcg inhaler price on outcomesâ, by Julien Dreyfus from the Centre Cardiologique du Nord in Saint-Denis, France, and colleagues. The authors sought to identify determinants of in-hospital and mid-term outcomes after isolated tricuspid valve surgery as little is known regarding the impact of tricuspid regurgitation (TR), its mechanism, and clinical presentation.5 Among â¼5600 consecutive adult patients who underwent tricuspid valve surgery at 12 French tertiary centres in 2007â2017 collected from a mandatory administrative database, the authors identified 466 patients who underwent an isolated tricuspid valve surgery. Most patients presented with advanced disease [47% in New York Heart Association (NYHA) class III/IV, 57% with right-sided heart failure signs].
TR was functional in 49% (22% with prior left-sided heart valve surgery and 27% isolated) and organic in 51% (infective endocarditis in 31% and other causes in 20%) symbicort 160mcg 4.5mcg inhaler price. In-hospital mortality and major complication rates were 10% and 31%, respectively. Rates of survival and survival free of heart failure readmission were 75% and 62% at 5 years symbicort 160mcg 4.5mcg inhaler price. Independent determinants of outcomes were NYHA class III/IV [odds ratio (OR) 2.7], moderate/severe right ventricular dysfunction (OR 2.6), and lower prothrombin time (OR 0.9), while the mechanism of TR was not associated with the outcomes.The authors conclude that isolated tricuspid valve surgery is associated with high mortality and morbidity, both in hospital and during follow-up, predicted by the severity of the presentation but not by the mechanism of TR. The results suggest that tricuspid valve interventions should be performed earlier in the course of the disease.
The manuscript is accompanied by an Editorial symbicort 160mcg 4.5mcg inhaler price by Victoria Delgado from the Leiden University Medical Center in the Netherlands and colleagues.6 The authors note that while data on the efficacy and durability of current transcatheter therapies are awaited, granular data such as those reported in the present article by Dreyfus et al.5 are important to highlight the need for early referral for isolated tricuspid valve intervention in patients with severe TR.Mitral annular calcification (MAC) is a common degenerative mitral valve disease characterized by calcification at the level of the mitral annulus that can be associated with significant mitral valve dysfunction including both stenosis and regurgitation. MAC is associated with female sex, advanced age, chronic kidney disease, and multiple cardiovascular risk factors, and prevalence ranges from 8% to 15% in the general population and reaches as high as 40% among the elderly. In a clinical research manuscript entitled âPrognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunctionâ, Philippe Bertrand from the Massachusetts General Hospital in Massachusetts, USA, and colleagues sought to define the natural history of patients with MAC-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient and impact of concomitant mitral regurgitation (MR).7 The institutional echocardiography database was examined for the period 2001â2019 for all patients with MAC and mean gradient (MG) â¥3 mmHg. About 5700 patients were stratified by MG into low (3â5 mmHg), mid (5â10 mmHg), and high (â¥10 mmHg) gradient symbicort 160mcg 4.5mcg inhaler price. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, and chronic kidney disease).
Mean transmitral pressure symbicort 160mcg 4.5mcg inhaler price gradient was independently associated with mortality [adjusted hazard ratio (HR) 1.064 per 1 mmHg increase). MR severity was associated with mortality at low gradients but not at higher gradients.Bertrand and colleagues conclude that in MAC-related mitral valve dysfunction, mean transmitral gradient is associated with increased mortality after adjustment for age, sex, and MAC-related risk factors. Concomitant MR is associated with excess mortality in low gradient ranges but gradually loses prognostic importance at higher gradients, indicating prognostic utility of the transmitral gradient in MAC regardless of MR severity. The manuscript is accompanied by an Editorial by Rebecca Hahn from Columbia University in New York, USA.8 who notes that any echocardiographic evidence for annular calcification may be an indication to use advanced multimodality imaging and novel biomarkers since these new tools may be the key to unlocking the mystery of intracardiac calcification and allow early detection and disease prevention.Cardiac myxomas usually develop symbicort 160mcg 4.5mcg inhaler price in the atria and consist of an acid mucopolysaccharide-rich myxoid matrix with polygonal stromal cells scattered throughout. These human benign tumours are a valuable research model because of the rarity of cardiac tumours, their clinical presentation, and uncertain origin.
In a Translational Research article entitled âAtrial myxomas arise from multipotent cardiac stem cellsâ, Mariangela Scalise from the Magna Graecia University in Catanzaro, Italy, and colleagues assessed whether human adult cardiac stem cells give rise to myxoma stromal cells.9 The authors collected and analysed 23 myxomas for the presence of multipotent cardiac stem cells. They detected myxoma cells symbicort 160mcg 4.5mcg inhaler price positive for c-kit. Most of the c-kit-positive cells were blood lineage-committed cells. However, blood lineage-uncommitted symbicort 160mcg 4.5mcg inhaler price c-kit-positive cardiac myxoma cells expressed stemness and cardiac progenitor cell transcription factors. Approximately 10% of the blood lineage-uncommitted c-kit-positive cardiac myxoma cells expressed calretinin, a characteristic of myxoma stromal cells.
In vitro, blood lineage-uncommitted c-kit-positive cardiac myxoma cells secreted chondroitin-6-sulfate and hyaluronic acid, which are the main components of the gelatinous myxoma matrix in vivo, and showed clonogenic, self-renewing, and sphere-forming properties (Figure 1). Figure 1The main findings of the study showing that cardiac myxomas arise from multipotent symbicort 160mcg 4.5mcg inhaler price c-kitpos/CD45neg/CD31neg myxoma tumour initiating cells and the working hypothesis of their direct derivation from normal c-kitpos/CD45neg/CD31neg cardiac stem/progenitor cells transformed by specific miRNA modulation (from Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza C, Cianflone E, Mancuso T, Aquila I, Salerno L, Nassa G, Agosti V, De Angelis A, Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto P, De Feo M, Viglietto G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells. See pages 4332â4345).Figure 1The main findings of the study showing that cardiac myxomas arise from multipotent c-kitpos/CD45neg/CD31neg myxoma tumour initiating cells and the working hypothesis of their direct derivation from normal c-kitpos/CD45neg/CD31neg cardiac stem/progenitor cells transformed by specific miRNA modulation (from Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza symbicort 160mcg 4.5mcg inhaler price C, Cianflone E, Mancuso T, Aquila I, Salerno L, Nassa G, Agosti V, De Angelis A, Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto P, De Feo M, Viglietto G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells.
See pages 4332â4345).The authors conclude that human myxoma is the first described cardiac stem cell-related human cardiac disease. This manuscript is accompanied by an Editorial by Mark Alan Sussman from the San Diego symbicort 160mcg 4.5mcg inhaler price State University in California, USA10 who notes that Scalise et al. Reveal the fundamental contribution of cardiac stem cells to atrial myxomas, offering provocative and tantalizing new insights for myocardial biology as well as strategic approaches to translational applications.Management of VHD has dramatically changed over the last few decades. The primary goal has moved away from relieving symptoms once they occur to optimizing long-term morbidity and mortality, which requires timely intervention. Early symptoms (the start of a decline in exercise capacity/exertional shortness of breath) are a clear trigger for intervention, but even asymptomatic patients may be at risk when followed conservatively.11,12 The issue contains a State of the Art symbicort 160mcg 4.5mcg inhaler price review article entitled âTiming of intervention in asymptomatic patients with valvular heart diseaseâ by Helmut Baumgartner from the University Hospital Muenster in Germany, and colleagues.
The authors note that recommendations for treatment of patients with symptoms due to severe valvular disease are based on a foundation of solid evidence.4 However, when to intervene in asymptomatic patients remains controversial, and decision requires careful individual weighing of the potential benefits against the risk of intervention and its long-term consequences. The primary rationale for earlier intervention is prevention of irreversible left ventricular (LV) myocardial changes that might result in later clinical symptoms and symbicort 160mcg 4.5mcg inhaler price adverse cardiac events. Various outcome predictors have been identified that facilitate decision-making. This review summarizes current recommendations and discusses recently published data that challenge them suggesting even earlier intervention. In adults with asymptomatic aortic stenosis, emerging risk markers include very severe valve obstruction, elevated serum natriuretic peptide levels, symbicort 160mcg 4.5mcg inhaler price and imaging evidence of myocardial fibrosis or increased extracellular myocardial volume.
Currently, transcatheter aortic valve implantation (TAVI) is not recommended for treatment of asymptomatic severe aortic stenosis although this may change in the future. In patients with aortic regurgitation, the potential benefit of early intervention in preventing LV dilation and dysfunction must be balanced against the long-term risk of a prosthetic valve, a particular concern because severe aortic regurgitation often occurs in younger patients with a congenital bicuspid valve. In patients with mitral stenosis, the option of transcatheter mitral balloon symbicort 160mcg 4.5mcg inhaler price valvotomy tilts the balance towards earlier intervention to prevent atrial fibrillation, embolic events, and pulmonary hypertension. When chronic severe MR is due to mitral valve prolapse, anatomic features consistent with a high likelihood of a successful and durable valve repair favour early intervention. The authors conclude that optimal timing of intervention in adults with VHD is a constantly changing threshold that depends not only on the severity of valve disease but on the safety, efficacy, and long-term durability of our treatment options (Figure symbicort 160mcg 4.5mcg inhaler price 2).
Figure 2Weighing of risks and benefits of intervention in asymptomatic valvular heart disease. Aspects that need to be considered and key questions for decision-making. Arrhyth., arrhythmias symbicort 160mcg 4.5mcg inhaler price. GL, guidelines. HF, heart failure.
Interv., intervention symbicort 160mcg 4.5mcg inhaler price. LA, left atrium. LV, left symbicort 160mcg 4.5mcg inhaler price ventricle. Pulm., pulmonary. VHD, valvular heat disease (from Baumgartner H, Iung B, Otto CM.
Timing of intervention in asymptomatic patients with valvular heart disease symbicort 160mcg 4.5mcg inhaler price. See pages 4349â4356).Figure 2Weighing of risks and benefits of intervention in asymptomatic valvular heart disease. Aspects that symbicort 160mcg 4.5mcg inhaler price need to be considered and key questions for decision-making. Arrhyth., arrhythmias. GL, guidelines.
HF, heart symbicort 160mcg 4.5mcg inhaler price failure. Interv., intervention. LA, left atrium. LV, left ventricle symbicort 160mcg 4.5mcg inhaler price. Pulm., pulmonary.
VHD, valvular heat disease (from Baumgartner H, Iung B, Otto symbicort 160mcg 4.5mcg inhaler price CM. Timing of intervention in asymptomatic patients with valvular heart disease. See pages 4349â4356).The issue is also complemented by Discussion Forum contributions. In a contribution entitled symbicort 160mcg 4.5mcg inhaler price âIs the national readmission database the right database to identify valve-in-valve transcatheter aortic valve replacement patients?. Â, Salik Nazir from the University of Toledo in Toledo, Ohio, USA comment on the recent publication âComparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs.
Reoperative surgical aortic valve replacement. A contemporary assessment of real-world outcomesâ by Sameer A Hirji from Harvard Medical School in Boston, Massachusetts, symbicort 160mcg 4.5mcg inhaler price USA, and colleagues.13,14 Hirji et al. Respond in a separate comment.15In a contribution entitled âVariable rate of stroke after transcatheter aortic valve replacement with self-expandable valves. More doubts symbicort 160mcg 4.5mcg inhaler price than certaintiesâ, Marco Ferlini from the Policlinico San Matteo in Pavia, Italy comment on the recent article âComparison of newer generation self-expandable vs. Balloon-expandable valves in transcatheter aortic valve implantation.
The randomized SOLVE-TAVI trialâ.16,17 Thiele et al. Respond in symbicort 160mcg 4.5mcg inhaler price a separate comment.18The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Muñoz D, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739â2791.2Binder symbicort 160mcg 4.5mcg inhaler price RK, Dweck M, Prendergast B.
The year in cardiology. Valvular heart symbicort 160mcg 4.5mcg inhaler price disease. Eur Heart J 2020;41:912â920.3Lüscher TF. Valvular heart disease. Improved procedural success and prediction symbicort 160mcg 4.5mcg inhaler price of outcomes.
Eur Heart J 2020;41:899â902.4Baumgartner H, Iung B, Otto CM. Timing of symbicort 160mcg 4.5mcg inhaler price intervention in asymptomatic patients with valvular heart disease. Eur Heart J 2020;41:4349â4356.5Dreyfus J, Flagiello M, Bazire B, Eggenspieler F, Viau F, Riant E, Mbaki Y, Bohbot Y, Eyharts D, Senage T, Dubrulle H, Nicol M, Doguet F, Nguyen V, Coisne A, Le Tourneau T, Lavie-Badie Y, Tribouilloy C, Donal E, Tomasi J, Habib G, Selton-Suty C, Raffoul R, Iung B, Obadia JF, Messika-Zeitoun D. Isolated tricuspid valve surgery. Impact of aetiology and clinical presentation symbicort 160mcg 4.5mcg inhaler price on outcomes.
Eur Heart J 2020;41:4304â4317.6Delgado V, Ajmone Marsan N, Bax JJ. The difficult decision of when and in whom to perform isolated tricuspid valve surgery. Eur Heart symbicort 160mcg 4.5mcg inhaler price J 2020;41:4318â4320.7Bertrand, PB, Churchill, TW, Yucel, E, Namasivayam, M, Bernard, S, Nagata, Y, He, W, Andrews, CT, Picard, MH, Weyman, AE, Levine, RA and Hung, J. Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction. Eur Heart symbicort 160mcg 4.5mcg inhaler price J 2020;41:4321â4328.8Hahn RT.
Degenerative mitral stenosis. Interpreting the meaning of mean gradient. Eur Heart J 2020;41:4329â4331.9Scalise M, Torella M, Marino F, Ravo M, Giurato G, Vicinanza C, Cianflone E, Mancuso T, Aquila symbicort 160mcg 4.5mcg inhaler price I, Salerno L, Nassa G, Agosti V, De Angelis A, Urbanek K, Berrino L, Veltri P, Paolino D, Mastroroberto P, De Feo M, Viglietto G, Weisz A, Nadal-Ginard B, Ellison-Hughes GM, Torella D. Atrial myxomas arise from multipotent cardiac stem cells. Eur Heart J 2020;41:4332â4345.10Sussman MA.
Atrial myxoma symbicort 160mcg 4.5mcg inhaler price. The cardiac chameleon. Eur Heart J 2020;41:4346â4348.11Pellikka PA symbicort 160mcg 4.5mcg inhaler price. Predicting outcome in asymptomatic aortic stenosis. Should we measure the severity of obstruction or its physiological consequences?.
Eur Heart J 2010;31:2191â2193.12Singh A, Greenwood JP, symbicort 160mcg 4.5mcg inhaler price Berry C, Dawson DK, Hogrefe K, Kelly DJ, Dhakshinamurthy V, Lang CC, Khoo JP, Sprigings D, Steeds RP, Jerosch-Herold M, Neubauer S, Prendergast B, Williams B, Zhang R, Hudson I, Squire IB, Ford I, Samani NJ, McCann GP. Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis. The PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) Study. Eur Heart J symbicort 160mcg 4.5mcg inhaler price 2017;38:1222â1229.13Nazir S, Ahuja KR, Alamir MA. Is the national readmission database the right database to identify valve-in-valve transcatheter aortic valve replacement patients?.
Eur Heart J 2020;41:4357.14Hirji SA, Percy ED, Zogg CK, Malarczyk A, Harloff MT, Yazdchi symbicort 160mcg 4.5mcg inhaler price F, Kaneko T. Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs. Reoperative surgical aortic valve replacement. A contemporary symbicort 160mcg 4.5mcg inhaler price assessment of real-world outcomes. Eur Heart J 2020;41:2747â2755.15Hirji S, Zogg CK, Kaneko T.
The utility of the nationwide symbicort 160mcg 4.5mcg inhaler price readmissions database in understanding contemporary transcatheter aortic valve replacement outcomes. Eur Heart J 2020;41:4358â4359.16Ferlini M, Mauri S. Variable rate of stroke after transcatheter aortic valve replacement with self-expandable valves. More doubts than certainties symbicort 160mcg 4.5mcg inhaler price. Eur Heart J 2020;41:4360â4361.17Thiele H, Kurz T, Feistritzer HJ, Stachel G, Hartung P, Eitel I, Marquetand C, Nef H, Doerr O, Lauten A, Landmesser U, Abdel-Wahab M, Sandri M, Holzhey D, Borger M, Ince H, Ãner A, Meyer-Saraei R, Wienbergen H, Fach A, Frey N, König IR, Vonthein R, Rückert Y, Funkat AK, de Waha-Thiele S, Desch S.
Comparison of newer generation self-expandable vs. Balloon-expandable valves in symbicort 160mcg 4.5mcg inhaler price transcatheter aortic valve implantation. The randomized SOLVE-TAVI trial. Eur Heart J 2020;41:1890â1899.18Thiele H, symbicort 160mcg 4.5mcg inhaler price Abdel-Wahab M, Desch S. Stroke rates after transcatheter aortic valve replacement.
Does valve choice play a role?. Eur symbicort 160mcg 4.5mcg inhaler price Heart J 2020;41:4362. Published on behalf of the European Society of Cardiology. All rights reserved. © The symbicort 160mcg 4.5mcg inhaler price Author(s) 2020.
For permissions, please email. Journals.permissions@oup.com.âVi-R(e)alâ Learning symbicort 160mcg 4.5mcg inhaler price Methods. Opportunity amidst adversityâLearn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expertââââââââââââââââââââââââââââââââââââââââSir William OslerCardiology training in most parts of the world involves rotations in the outpatient department, inpatient services, non-invasive imaging laboratories, and cardiac catheterization laboratories with or without dedicated research time based on each programme and individual.1â4 As per the World Health Organization, anti inflammatory drugs has been a symbicort since 11 March 2020.5 In most places, specialists and trainees of different specialties have started managing patients with anti inflammatory drugs, as it was and still is the need of the hour globally. As a consequence, Cardiology Fellows across the world have had a significant impact on their training,6 teaching and procedural volumes. The Department of Cardiology at SRIHER,7 Chennai, India has observed this deficiency and made substantial changes to our curriculum focusing on virtual meetings starting from the end of symbicort 160mcg 4.5mcg inhaler price March 2020.
Virtual meetings included journal clubs, seminars, technical aspects of procedures, and clinical case presentations. Although most of the topics were informative and educational, the virtual case presentations were perceived to be the most interesting. Initially, it was conducted by symbicort 160mcg 4.5mcg inhaler price our own faculties to our departmental Fellows. Later, we realized that such virtual case presentations would be the ânew normalâ during this anti inflammatory drugs symbicort for all the Fellows in the country. This encouraged us to conduct the same as an e-course for symbicort 160mcg 4.5mcg inhaler price the benefit of the fellows.Currently, we are undertaking a series of virtual case presentations, which are being chaired by eminent faculties from several institutes of national importance in India.
Though there is no parallel to bedside teaching, these virtual case presentations and lectures conducted by distinguished faculties across the country brought a significant impact on the education of our fellows. We believe that an involvement from major societies across the globe in these types of activities that are focused on future leaders is paramount importance. We have symbicort 160mcg 4.5mcg inhaler price described in brief the advantages and disadvantages of the virtual learning series in Table 1. Table 1Advantages and disadvantages of âVi-R(e)alâ learning methods Advantages. Disadvantages symbicort 160mcg 4.5mcg inhaler price.
Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Advantages. Disadvantages. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions symbicort 160mcg 4.5mcg inhaler price thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Table 1Advantages and disadvantages of âVi-R(e)alâ learning methods Advantages. Disadvantages. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue Advantages.
Disadvantages symbicort 160mcg 4.5mcg inhaler price. Only way of learning during anti inflammatory drugs era It can never replace bedside teaching Increases the knowledge base Cost associated with devices and internet services Creates a new field for interaction of students and faculties from different institutions thereby decreasing the disparities of training between different centres Need to have good spectrum of internet service to have better audio and video qualities Provides a platform to clear doubts by many people at a time Eye to eye co-ordination is missed which may affect the attention of the candidate or participants Improves the candidate and examiners relationship Multiple topics can be discussed while discussing the main issue As Sir Osler rightly said, âThe very first step towards the success of any occupation is to become interested in itâ. We see Fellows taking interest in attending such virtual case presentations where they gain knowledge from different groups of faculties, which widens their horizons.This anti inflammatory drugs symbicort enabled us to search for opportunities amidst adversity symbicort 160mcg 4.5mcg inhaler price that inspired such virtual case presentations and drove us to adapt by using e-simulation techniques to help surgical or intervention-oriented fields. We feel that while the virtual teaching sessions can never replace Oslerâs method of bedside learning, they will strengthen its value by complementing it in real-time, leading to a new-era of teaching which we call âVi-R(e)alâ learning methods. We define âVi-R(e)alâ learning methods as a futuristic learning tool where e-forums, courses, and simulations will be taught by national and international experts.
We believe that such a method will symbicort 160mcg 4.5mcg inhaler price improve training globally and aid in serving humanity better. We also believe that âVi-R(e)alâ learning methods could soon become the norm for the future, to increase knowledge base and decrease disparities in training between different centres.âThe learned make each land their own, in every city find a home;Who, till they die. Learn nought, along what weary ways they roam!. ÂAs expressed in the above translated couplet from the Thirukkural,8 which was written over 2000 years ago by the acclaimed Tamil poet Thiruvalluvar, wherein he pondered that education would open a gateway to the world and in true sense we are living that vision today by uniting global education through web-based platforms.Conflict of interest. None declared.
ReferencesReferences are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email.
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