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About This TrackerThis tracker provides the number of confirmed cases and deaths from novel hypertension by country, the trend in confirmed case and death counts by country, and a lasix 40mg price global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) hypertension Resource Center’s hypertension medications Map and the World Health Organization’s (WHO) hypertension Disease (hypertension medications-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About hypertension medications lasix 40mg price hypertensionIn late 2019, a new hypertension emerged in central China to cause disease in humans. Cases of this disease, known as hypertension medications, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the lasix represents a public health emergency of international concern, and on January 31, 2020, the U.S.

Department of Health and Human Services declared it lasix 40mg price to be a health emergency for the United States.As of July 7, 2021, of the estimated 3.3 billion hypertension medications treatment doses administered globally, most had been provided in a small number of countries only. For much of the world, particularly for those living in low- and middle-income countries, hypertension medications treatments remain out of reach. While international efforts, such as COVAX and additional treatment donations are seeking to increase global treatment access, several estimates suggest that many countries may not achieve substantial levels of vaccination until at least 2023.Drawing on and complementing existing efforts that track global treatment access, such lasix 40mg price as Our World in Data, the Launch and Scale Speedometer, and Bloomberg’s treatment Tracker, we examine several measures of global treatment equity in an effort to assess where the biggest gaps are and whether they are narrowing or getting worse. Specifically, we group countries by income and by region and look at:Share of the total population having received at least one treatment doseRate of first treatment doses administered (Using the 7-day rolling average per 1,000,000 people)Based on the current rate of treatment doses administered, we also estimate how much the pace would need to increase in order to reach global treatment coverage goals set by the World Health Organization, World Trade Organization, International Monetary Fund, and World Bank. 40% coverage by the end of 2021 and 60% by mid-2022.

We do this at the country-level, and for countries by income group and regional classification.As we find here, there are wide disparities lasix 40mg price in access by income and by region (especially where these overlap), with low-income countries (LICs) in particular lagging far behind, followed closely by lower middle-income countries (LMICs), and Africa lagging behind all other regions. If current rates continue, most low-income countries and most countries in Africa are not on track to meet global vaccination targets.hypertension medications Vaccinations by Country Income There are large differences in the share of the population that has received at least one treatment dose by country income, with LMICs lagging significantly behind. As of July 7, whereas more than half of individuals (51%) have received at least one dose in high-income countries (HICs), only 1% of the population in LICs, 14% in LMICs, and 31% in upper middle-income countries (UMICs) have received at least one dose (see Figure 1 and Figure 2). Three countries (China, India and the United States) account for the majority (57%) of all first doses administered lasix 40mg price globally. When removed, the difference between HICs and middle-income countries becomes even starker, with HICs still well ahead of other income groups in share of population that has received at least one dose (see Figure 3).

See Table 1 for the full list of countries in each income group by share of lasix 40mg price population that has received at least one dose. Similarly, there is also a large gulf in the rate at which treatments are being administered by country income. While the daily rate of first doses administered varies by country (see Figure 4), HICs were administering first doses at a rate nearly 2 times the rate in LMICs and in UMICs, and nearly 30 times the rate in LICs. See Table 2 for a lasix 40mg price breakdown of top countries in each income group by coverage and daily administration rates. If current trends continue, these disparities are likely to grow, and LICs are unlikely to meet vaccination targets.

Based on current vaccination rates (using rates of first doses administered), HICs and UMICs are on track to have 40% or more of their populations having received at least one dose by the end of the year, whereas LMICs would need to increase their daily rate by 1.03 times and LICs would need to increase their daily rate by nearly 19 times in order to meet the same goal. HICs, UMICs, and LMICs are on track to have 60% or more of their populations having received at least lasix 40mg price one dose by mid-2022, while LICs would need to increase their daily rate by 14 times (see Figure 5). Certain countries, primarily HICs, have already met some of these vaccination targets. hypertension medications Vaccinations by RegionAs with country income, there are large differences in the share of the population that has received at least one treatment dose among regions, with lasix 40mg price the highest coverage in Europe and smallest in Africa. As of July 7, the region with the highest coverage is Europe (40%) followed by the Americas (39%) and the Western Pacific (37%).

Africa has the lowest coverage (2%) (see Figure 6 and Figure 7). Similar to income level, China, India and the U.S lasix 40mg price. Are driving trends in vaccination coverage in their respective regions. For instance, China accounts for 87% of first doses administered in Western Pacific, the US accounts for 46% in the Americas, and India accounts for 84% in South-East Asia. When removing these countries, the differences between Europe and the Americas, Western Pacific, and South-East Asia lasix 40mg price are larger (see Figure 8).

See Table 3 for a breakdown of top countries in each region by coverage and daily administration rates. The rate of treatment administration is highest in Europe lasix 40mg price and the Americas and lowest in Africa. While rates of first doses administered vary by country (see Figure 9), Europe and the Americas currently have the highest rate of daily doses administered. These regions are vaccinating at a rate approximately 1.5 times that of South-East Asia, nearly 3 times that of Eastern Mediterranean, 4 times that of the Western Pacific, and more than 13 times higher that of Africa. See Table 4 for a breakdown of top countries in lasix 40mg price each region by coverage and daily administration rates.

These disparities are likely to grow based on current vaccination trends. Western Pacific, Europe, the Americas, and South-East Asia lasix 40mg price are all ahead of schedule toward reaching 40% by the end of 2021 while Eastern Mediterranean would need to increase its rate of daily first doses administered by nearly 1.6 times the current rate, and Africa by approximately 11 times the current rate. They are also ahead of schedule to reach 60% by mid-2022, while Eastern Mediterranean would need to increase its rate of daily first doses administered by approximately 1.4 times the current rate, and Africa by approximately 8 times the current rate (see Figure 10). Certain countries, primarily those in Europe, have already met some of these vaccination targets. ImplicationsThese findings underscore an ongoing equity gap in access to hypertension medications vaccinations around the world, particularly for those living in the poorest countries and in countries in lasix 40mg price Africa.

Furthermore, they suggest that if current rates continue, some of these disparities may grow and many low-income countries will not meet global targets of vaccinating 40% of each countries’ population by end of 2021 and 60% by mid-2022. Increasing treatment supplies and stepping up the pace of vaccinations in those countries lagging furthest behind can narrow the equity gap and help all countries achieve hypertension medications vaccination coverage goals. Vaccination Data lasix 40mg price. We used country-level vaccination data on doses administered, provided by Our World in Data (OWID), to assess global vaccination trends at the income and regional level. Totals for some entities were lasix 40mg price combined (Taiwan, Hong Kong, and Macao included as part of China, and Jersey and Guernsey were combined and reported as the Channel Islands).

Where missing data in the daily doses provided existed between two dates for a country, we estimated the number of doses administered each day between the two reported dates assuming a linear distribution. For countries that have stopped reporting data, we assumed no change in new doses administered. For countries that report total doses administered but not share of population that has lasix 40mg price received at least one dose, we use OWID’s suggested methodology and calculated a lower-bound estimate. As a result, our estimates are conservative and the actual share of the population receiving one dose is likely higher. For data on daily administration of first doses, we calculated the rolling 7-day average in daily change of the number of people who have received at least one dose.

For projecting increased rate needed for groupings to lasix 40mg price reach certain benchmarks (40% by end of 2021 and 60% by July 1, 2022), we calculated the rate needed to reach these benchmarks for each grouping, based on number of first doses already administered and population, and calculated the percentage change from the current daily rate in first doses being administered to the increased rate needed to reach these targets. Lastly, for all data, to account for any lag in country reporting, we use data up to one week prior (July 7, 2021).Population Data. Population data were obtained from the United Nations World Population Prospects using lasix 40mg price 2020 estimates for total population (and the CIA World Factbook for Serbia and Kosovo). Totals for some entities were combined (Taiwan, Hong Kong, and Macao included as part of China), while others were separated (separating Kosovo from Serbia).Income Data. Income classifications were obtained using World Bank data.

Entities lacking an income classification lasix 40mg price were excluded from the income-level analysis.Regional Data. Region classifications were obtained using World Health Organization data. Entities lacking a region classification were excluded from the region-level analysis..

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How to cite Cialis for sale this natural lasix for humans article:Singh OP. Comprehensive Mental Health Action Plan 2013–2030. We must natural lasix for humans rise to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health natural lasix for humans Assembly accepted the updates to the action plan, including updates to the target options for indicators and implementation.

This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental natural lasix for humans health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an opportunity for us to expand psychiatry by being involved in general medical care and reduce natural lasix for humans stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization.

Mental Health Action natural lasix for humans Plan 2013-2020. Geneva. World Health natural lasix for humans Organization. 2013. 2.World Health natural lasix for humans Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. 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_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 27];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence.

This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used.

The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis.

The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation.

Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial.

It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management.

Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

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4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

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Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L.

Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles. Psychol Psychother 1983;20:368-75.

17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B.

Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL. A social-neuroscience perspective on empathy.

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR.

Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to cite lasix 40mg price this article:Singh OP. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the challenge lasix 40mg price. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly lasix 40mg price accepted the updates to the action plan, including updates to the target options for indicators and implementation.

This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 lasix 40mg price and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an opportunity for us to expand psychiatry by being involved in general medical care and reduce lasix 40mg price stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization.

Mental Health lasix 40mg price Action Plan 2013-2020. Geneva. World Health lasix 40mg price Organization. 2013. 2.World Health lasix 40mg price Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. 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_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 27];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence.

This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used.

The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis.

The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation.

Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial.

It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management.

Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

Alcohol dependence. A public health perspective. Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence.

Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment. Int J Psychoanal 1972;53:51-9. 7.Miller WR.

Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin.

A factor-analytic study. Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L.

Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles. Psychol Psychother 1983;20:368-75.

17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B.

Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL. A social-neuroscience perspective on empathy.

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR.

Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

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€œDespite advances in the management of hypertension medications since the onset of the lasix, we need more therapies to accelerate recovery and additional clinical research will be essential to identifying therapies that slow disease progression and lower mortality in the sicker patients,” she said. The data supporting the authorization requrest is based on a randomized, double-blind, placebo-controlled clinical trial conducted by the National Institute of Allergy and Infectious Diseases. The trial followed buy lasix pill patients for 29 days and included 1,033 patients with moderate to severe hypertension medications. In the study, 515 patients received baricitinib plus remdesivir, and 518 patients received placebo plus remdesivir.

In reviewing the combination, the FDA "determined that it is reasonable to believe that baricitinib, in combination with remdesivir, may be effective in treating hypertension medications for the authorized population" and the known benefits outweigh the known and potential risks. Additionally, there buy lasix pill are no adequate, approved, and available alternatives for the treatment population.By Robert Preidt HealthDay Reporter FRIDAY, Nov. 20, 2020 (HealthDay News) -- The antiviral drug remdesivir is not recommended for hospitalized hypertension medications patients because there's no evidence that it reduces their need for ventilation or improves their chances of survival, a World Health Organization panel said Thursday. Remdesivir is regarded as a potential treatment for severe hypertension medications and is used to treat hospitalized patients, but there is uncertainty about its effectiveness.

Nevertheless, the U.S buy lasix pill. Food and Drug Administration approved the drug to treat hospitalized hypertension medications patients in October. In the new assessment, the WHO panel of experts analyzed data from four international randomized trials that assessed several treatments for hypertension medications and included more than 7,000 hospitalized hypertension medications patients. The panel -- which included four people who've had hypertension medications -- concluded that buy lasix pill remdesivir has no meaningful impact on the risk of death or any other important patient outcomes, such as the need for mechanical ventilation or how long it takes for their condition to improve.

The results of the trials don't prove that remdesivir has no benefit. Instead, they provide no evidence that the drug improves patient outcomes, the panel explained in an article published Nov. 19 in buy lasix pill the BMJmedical journal. However, given the risk of significant harm, the relatively high cost, and the demands on health care staff (remdesivir must be given intravenously), their recommendation is appropriate, the panel said.

The panel also said they support continued enrollment into trials evaluating the use of remdesivir in hypertension medications patients, especially to provide more reliable evidence for specific groups of patients. The future use of remdesivir in treating hypertension medications patients is unclear, given that it's unlikely to be the lifesaving drug many have hoped for, American journalist Jeremy Hsu wrote in buy lasix pill a linked article in the journal. He also noted that alternative treatments -- such as the inexpensive and widely available corticosteroid dexamethasone, which has been shown to reduce death risk in severely ill hypertension medications patients -- are now part of the discussions about remdesivir's worth as a hypertension medications treatment. "It's become clear that remdesivir, at best, has a marginal benefit if any on clinical improvement," said Dr.

Amesh Adalja, a senior scholar at buy lasix pill the Johns Hopkins Center for Health Security in Baltimore. "It is not surprising, therefore, that the WHO guideline committee does not support its use, underscoring the need for better treatments that more meaningfully impact patient outcomes." More information For more on treatments for severe hypertension medications, go to the U.S. Centers for Disease Control and Prevention. SOURCES.

BMJ, news release, Nov. 19, 2020. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, BaltimoreBy Robert Preidt HealthDay Reporter FRIDAY, Nov. 20, 2020 (HealthDay News) -- Add stress-related hair loss to the many problems caused by the hypertension lasix.

"I've had patients coming in recently with stress-related hair loss, who tell me they were so worried about dying earlier this year or even that they had hypertension medications. But they don't see the effects until three months later," said dermatologist Dr. Ohara Aivaz of Cedars-Sinai Medical Center in Los Angeles. "It throws the patient off because the stress has resolved, and yet, the physical manifestation is happening now," Aivaz said in a hospital news release.

Stress-related hair loss typically occurs three months or more after a stressful event. Why it takes that long isn't clear, but the body may prematurely force hair into the dormant phase of its growth cycle, which eventually leads to the hair root shrinking and falling out, experts say. If you do have hair loss, it's a good idea to have a doctor check for a thyroid issue or anemia. If stress is the cause, hair loss supplements and time can help, according to Aivaz.

"If you remove the trigger and the stress level decreases, the majority of the time hair loss stops on its own, and the patient regrows the lost hair because their follicles are still active and healthy," she said. As the lasix has progressed, Aivaz and other dermatologists have also had more patients seeking treatment for skin issues caused by increased hand-washing and stress. In addition to hair loss, stress can trigger flares of acne, dandruff and eczema, particularly among older people who are more vulnerable to hypertension medications and may have been worried about their health and finances, Aivaz said. For eczema, she recommends taking short, lukewarm showers of 10 minutes or less using fragrance-free soap in the areas most often affected (armpits, groin, feet).

But don't overdo it, she noted. "When skin is really dry, even gentle soap can strip natural oils. Don't wash something that's not soiled," Aivaz said. "Lather soap in your hands, and skip the washcloth, which also can strip your skin." More information For more on stress, see the U.S.

National Institute of Mental Health. SOURCE. Cedars-Sinai Medical Center, news release, Nov. 16, 2020Nov.

20, 2020 -- American pharmaceutical company Pfizer, and its German partner BioNTech, said Friday they had submittted for approval an application for an experimental hypertension treatment. But don’t start standing in line yet for a shot. If the FDA does grant emergency use authorization to Pfizer, a hypertension treatment would be rolled out in phases. Some Americans might not get it until mid-2021.

An FDA advisory committee is scheduled to meet Dec. 8-10 and could discuss both the Pfizer treatment and one produced by Moderna, which has also said it plans to apply for emergency use authorization. Both are two-shot treatments. If the committee approves Pfizer’s treatment, distribution could begin within 24 hours.

The Pfizer treatment has already been manufactured under a $1.95 billion contract with the government. And some states have already made plans for how to distribute the treatment. Who Gets the treatment First?. The CDC’s Advisory Committee on Immunization Practices will decide on distribution.

USA Today reported that the National Academies of Sciences, Engineering, and Medicine advised the CDC on priorities. Those priorities are. Phase I, part I. Frontline health care, ambulance drivers, cleaners, and first responders.

This is about 5% of the U.S. Population. Phase I, part II. People with serious conditions like cancer and heart disease that puts them at a significantly higher risk of serious or death, as well as people over 65 in group living facilities such as nursing homes, homeless shelters, and prisons.

That’s about 10% of the population. Phase II. Everybody else over 65, teachers, child care workers, people with health conditions putting them at moderate risk, people under 65 in detention centers and people who work there, and critical workers who can’t avoid exposure to hypertension medications, such as public transit employees or food supply workers. That’s 30% to 35% of the population.

Phase III. Younger adults and people working in higher education, hotels, banks, exercise facilities, and factories. That’s 40% to 45% of the population. It’s unclear if children would be included in this group, USA Today said.

Phase IV. People who didn’t fit into any other phases -- 5% to 15% of the population. A timetable hasn’t been published, but Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases and the nation’s hypertension medications authority, recently said a hypertension treatment should be available to the general public sometime from April to July. Speed is crucial.

While the government makes decisions, the hypertension will continue to sicken Americans and stifle the national economy. The United States recorded its 250,000th hypertension-related death this week and has marked 11.5 million cases since the lasix started -- more than any other nation. On Thursday, the United States recorded 170,161 new confirmed cases and 2,000 deaths. States on the Clock Under President Donald Trump’s policy of letting states set their own policies for battling the hypertension medications lasix, the states would also be responsible for treatment distribution.

Some of them have already described plans. In Ohio, Gov. Mike DeWine announced 10 sites across the state that will receive the treatment once the FDA grants emergency use authorization, he said in a news release. €œOhio will first vaccinate those who are most at risk, including those who work in long-term care facilities, nursing homes, and other congregate-care facilities, high-risk health care workers, and first responders,” the release said.

In Minnesota, the Mayo Clinic says it’s ready to start vaccinations in late December, according to the Twin Cities Pioneer Press. €œWe’re very confident that we will have at least one treatment by the end of the year for at least a small, targeted population, which hasn’t been decided yet,” Melanie Swift, MD, said this week. New Jersey could receive its first shipment of treatments in late December.It's expected that @pfizer will be applying to the @US_FDA for an emergency use authorization for their new treatment – if approved, we'd expect our first shipment of 130,000 doses to arrive around Christmas— Governor Phil Murphy (@GovMurphy) November 20, 2020 Pfizer’s treatment would be the first approved for use in the United States. Clinical trials show the two-shot treatment was 95% effective in preventing s, the company said in a news release.

€œOur work to deliver a safe and effective treatment has never been more urgent, as we continue to see an alarming rise in the number of cases of hypertension medications globally,” Albert Bourla, PhD, Pfizer chairman and CEO, said in the release. The company is also submitting “rolling submissions” for approval from government agencies around the world. Others Also on the Way Other treatments may hit the market soon. Moderna said its treatment shows about 95% efficacy.

AstraZeneca and Johnson &. Johnson are in the late stages of their treatment clinical trials. An emergency use authorization, or EUA, is not the same as full approval. An EUA allows a drug to be made available during a health crisis before all testing is completed.

Normally, it takes years to develop a treatment, but the severity of the hypertension lasix caused the government to fast-track the process. EUAs can be withdrawn, as happened earlier this year when researchers found the antimalarial drug Hydroxychloroquine didn’t help people who had the hypertension. Because of high interest in the treatment, the FDA said this week that it will make the EUA process open to the public. "Today's transparency action is just one of a number of steps we are taking to ensure public confidence in our EUA review process for drugs and biological products, especially any potential hypertension medications treatments," FDA Commissioner Stephen Hahn, MD, said in a statement.

WebMD Health News Sources Pfizer. €œPfizer and BioNTech to Submit Emergency Use Authorization Request Today to the U.S. FDA for hypertension medications treatment.” U.S. Department of Health and Human Services.

€œU.S. Government Engages Pfizer to Produce Millions of Doses of hypertension medications treatment.” USA Today. "Expert panel recommends who should be first in line for hypertension medications treatment. Where will your family be?.

" “Fauci says the average American could get vaccinated against hypertension medications as soon as April. 'I would take the treatment.' ” Ohio Gov. Mike DeWine. €œhypertension medications update.

21-day statewide curfew.” Twin Cities Pioneer Press. "Mayo Clinic is preparing to start limited hypertension medications vaccinations in December." FDA.gov, letter from Rear Admiral Denise Hinton, chief scientist, June 15, 2020. FDA. €œhypertension medications Update.

FDA’s Ongoing Commitment to Transparency for hypertension medications EUAs.” © 2020 WebMD, LLC. All rights reserved..

Nov where to buy lasix water pill lasix 40mg price. 19, 2020 -- The FDA on Thursday granted emergency use authorization for the arthritis drug baricitinib to be used in combination with remdesivir to treat hospitalized adults and children with suspected or confirmed hypertension medications. The combination is meant for patients who need supplemental lasix 40mg price oxygen or mechanical ventilation.

Baricitinib plus remdesivir was shown in a clinical trial to reduce recovery time within 29 days of starting the treatment, compared with a control group who received placebo plus remdesivir, according to the FDA press release. The median time to recovery from hypertension medications was 7 days for the combination group vs. 8 days for those in the placebo plus lasix 40mg price remdesivir group.

Recovery was defined as either discharge from the hospital or "being hospitalized but not requiring supplemental oxygen and no longer requiring ongoing medical care," the agency said. The odds of a patient dying or needing a ventilator at day 29 was lower in the combination group compared with those taking placebo and remdesivir, although no specific data was provided. "For all of these endpoints, the effects were lasix 40mg price statistically significant," the agency stated.

Emergency use authorization allows doctors to use the drugs during a health crisis. Full approval takes much longer, and the research continues. "The FDA's emergency authorization of this combination therapy represents an incremental step forward in the treatment of hypertension medications in hospitalized patients, and FDA's first authorization of a drug that acts on the inflammation pathway," said Patrizia Cavazzoni, MD, acting director of the FDA's Center for Drug lasix 40mg price Evaluation and Research.

€œDespite advances in the management of hypertension medications since the onset of the lasix, we need more therapies to accelerate recovery and additional clinical research will be essential to identifying therapies that slow disease progression and lower mortality in the sicker patients,” she said. The data supporting the authorization requrest is based on a randomized, double-blind, placebo-controlled clinical trial conducted by the National Institute of Allergy and Infectious Diseases. The trial followed patients for 29 days and included 1,033 patients with lasix 40mg price moderate to severe hypertension medications.

In the study, 515 patients received baricitinib plus remdesivir, and 518 patients received placebo plus remdesivir. In reviewing the combination, the FDA "determined that it is reasonable to believe that baricitinib, in combination with remdesivir, may be effective in treating hypertension medications for the authorized population" and the known benefits outweigh the known and potential risks. Additionally, there are no adequate, approved, and available alternatives for the treatment lasix 40mg price population.By Robert Preidt HealthDay Reporter FRIDAY, Nov.

20, 2020 (HealthDay News) -- The antiviral drug remdesivir is not recommended for hospitalized hypertension medications patients because there's no evidence that it reduces their need for ventilation or improves their chances of survival, a World Health Organization panel said Thursday. Remdesivir is regarded as a potential treatment for severe hypertension medications and is used to treat hospitalized patients, but there is uncertainty about its effectiveness. Nevertheless, the lasix 40mg price U.S.

Food and Drug Administration approved the drug to treat hospitalized hypertension medications patients in October. In the new assessment, the WHO panel of experts analyzed data from four international randomized trials that assessed several treatments for hypertension medications and included more than 7,000 hospitalized hypertension medications patients. The panel -- which included four people lasix 40mg price who've had hypertension medications -- concluded that remdesivir has no meaningful impact on the risk of death or any other important patient outcomes, such as the need for mechanical ventilation or how long it takes for their condition to improve.

The results of the trials don't prove that remdesivir has no benefit. Instead, they provide no evidence that the drug improves patient outcomes, the panel explained in an article published Nov. 19 in the lasix 40mg price BMJmedical journal.

However, given the risk of significant harm, the relatively high cost, and the demands on health care staff (remdesivir must be given intravenously), their recommendation is appropriate, the panel said. The panel also said they support continued enrollment into trials evaluating the use of remdesivir in hypertension medications patients, especially to provide more reliable evidence for specific groups of patients. The future use of remdesivir in treating hypertension medications patients is unclear, given that it's unlikely to be the lifesaving drug many have hoped for, American journalist Jeremy Hsu wrote in a linked article in the journal lasix 40mg price.

He also noted that alternative treatments -- such as the inexpensive and widely available corticosteroid dexamethasone, which has been shown to reduce death risk in severely ill hypertension medications patients -- are now part of the discussions about remdesivir's worth as a hypertension medications treatment. "It's become clear that remdesivir, at best, has a marginal benefit if any on clinical improvement," said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security in lasix 40mg price Baltimore.

"It is not surprising, therefore, that the WHO guideline committee does not support its use, underscoring the need for better treatments that more meaningfully impact patient outcomes." More information For more on treatments for severe hypertension medications, go to the U.S. Centers for Disease Control and Prevention. SOURCES.

BMJ, news release, Nov. 19, 2020. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, BaltimoreBy Robert Preidt HealthDay Reporter FRIDAY, Nov.

20, 2020 (HealthDay News) -- Add stress-related hair loss to the many problems caused by the hypertension lasix. "I've had patients coming in recently with stress-related hair loss, who tell me they were so worried about dying earlier this year or even that they had hypertension medications. But they don't see the effects until three months later," said dermatologist Dr.

Ohara Aivaz of Cedars-Sinai Medical Center in Los Angeles. "It throws the patient off because the stress has resolved, and yet, the physical manifestation is happening now," Aivaz said in a hospital news release. Stress-related hair loss typically occurs three months or more after a stressful event.

Why it takes that long isn't clear, but the body may prematurely force hair into the dormant phase of its growth cycle, which eventually leads to the hair root shrinking and falling out, experts say. If you do have hair loss, it's a good idea to have a doctor check for a thyroid issue or anemia. If stress is the cause, hair loss supplements and time can help, according to Aivaz.

"If you remove the trigger and the stress level decreases, the majority of the time hair loss stops on its own, and the patient regrows the lost hair because their follicles are still active and healthy," she said. As the lasix has progressed, Aivaz and other dermatologists have also had more patients seeking treatment for skin issues caused by increased hand-washing and stress. In addition to hair loss, stress can trigger flares of acne, dandruff and eczema, particularly among older people who are more vulnerable to hypertension medications and may have been worried about their health and finances, Aivaz said.

For eczema, she recommends taking short, lukewarm showers of 10 minutes or less using fragrance-free soap in the areas most often affected (armpits, groin, feet). But don't overdo it, she noted. "When skin is really dry, even gentle soap can strip natural oils.

Don't wash something that's not soiled," Aivaz said. "Lather soap in your hands, and skip the washcloth, which also can strip your skin." More information For more on stress, see the U.S. National Institute of Mental Health.

SOURCE. Cedars-Sinai Medical Center, news release, Nov. 16, 2020Nov.

20, 2020 -- American pharmaceutical company Pfizer, and its German partner BioNTech, said Friday they had submittted for approval an application for an experimental hypertension treatment. But don’t start standing in line yet for a shot. If the FDA does grant emergency use authorization to Pfizer, a hypertension treatment would be rolled out in phases.

Some Americans might not get it until mid-2021. An FDA advisory committee is scheduled to meet Dec. 8-10 and could discuss both the Pfizer treatment and one produced by Moderna, which has also said it plans to apply for emergency use authorization.

Both are two-shot treatments. If the committee approves Pfizer’s treatment, distribution could begin their website within 24 hours. The Pfizer treatment has already been manufactured under a $1.95 billion contract with the government.

And some states have already made plans for how to distribute the treatment. Who Gets the treatment First?. The CDC’s Advisory Committee on Immunization Practices will decide on distribution.

USA Today reported that the National Academies of Sciences, Engineering, and Medicine advised the CDC on priorities. Those priorities are. Phase I, part I.

Frontline health care, ambulance drivers, cleaners, and first responders. This is about 5% of the U.S. Population.

Phase I, part II. People with serious conditions like cancer and heart disease that puts them at a significantly higher risk of serious or death, as well as people over 65 in group living facilities such as nursing homes, homeless shelters, and prisons. That’s about 10% of the population.

Phase II. Everybody else over 65, teachers, child care workers, people with health conditions putting them at moderate risk, people under 65 in detention centers and people who work there, and critical workers who can’t avoid exposure to hypertension medications, such as public transit employees or food supply workers. That’s 30% to 35% of the population.

Phase III. Younger adults and people working in higher education, hotels, banks, exercise facilities, and factories. That’s 40% to 45% of the population.

It’s unclear if children would be included in this group, USA Today said. Phase IV. People who didn’t fit into any other phases -- 5% to 15% of the population.

A timetable hasn’t been published, but Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases and the nation’s hypertension medications authority, recently said a hypertension treatment should be available to the general public sometime from April to July. Speed is crucial. While the government makes decisions, the hypertension will continue to sicken Americans and stifle the national economy.

The United States recorded its 250,000th hypertension-related death this week and has marked 11.5 million cases since the lasix started -- more than any other nation. On Thursday, the United States recorded 170,161 new confirmed cases and 2,000 deaths. States on the Clock Under President Donald Trump’s policy of letting states set their own policies for battling the hypertension medications lasix, the states would also be responsible for treatment distribution.

Some of them have already described plans. In Ohio, Gov. Mike DeWine announced 10 sites across the state that will receive the treatment once the FDA grants emergency use authorization, he said in a news release.

€œOhio will first vaccinate those who are most at risk, including those who work in long-term care facilities, nursing homes, and other congregate-care facilities, high-risk health care workers, and first responders,” the release said. In Minnesota, the Mayo Clinic says it’s ready to start vaccinations in late December, according to the Twin Cities Pioneer Press. €œWe’re very confident that we will have at least one treatment by the end of the year for at least a small, targeted population, which hasn’t been decided yet,” Melanie Swift, MD, said this week.

New Jersey could receive its first shipment of treatments in late December.It's expected that @pfizer will be applying to the @US_FDA for an emergency use authorization for their new treatment – if approved, we'd expect our first shipment of 130,000 doses to arrive around Christmas— Governor Phil Murphy (@GovMurphy) November 20, 2020 Pfizer’s treatment would be the first approved for use in the United States. Clinical trials show the two-shot treatment was 95% effective in preventing s, the company said in a news release. €œOur work to deliver a safe and effective treatment has never been more urgent, as we continue to see an alarming rise in the number of cases of hypertension medications globally,” Albert Bourla, PhD, Pfizer chairman and CEO, said in the release.

The company is also submitting “rolling submissions” for approval from government agencies around the world. Others Also on the Way Other treatments may hit the market soon. Moderna said its treatment shows about 95% efficacy.

AstraZeneca and Johnson &. Johnson are in the late stages of their treatment clinical trials. An emergency use authorization, or EUA, is not the same as full approval.

An EUA allows a drug to be made available during a health crisis before all testing is completed. Normally, it takes years to develop a treatment, but the severity of the hypertension lasix caused the government to fast-track the process. EUAs can be withdrawn, as happened earlier this year when researchers found the antimalarial drug Hydroxychloroquine didn’t help people who had the hypertension.

Because of high interest in the treatment, the FDA said this week that it will make the EUA process open to the public. "Today's transparency action is just one of a number of steps we are taking to ensure public confidence in our EUA review process for drugs and biological products, especially any potential hypertension medications treatments," FDA Commissioner Stephen Hahn, MD, said in a statement. WebMD Health News Sources Pfizer.

€œPfizer and BioNTech to Submit Emergency Use Authorization Request Today to the U.S. FDA for hypertension medications treatment.” U.S. Department of Health and Human Services.

€œU.S. Government Engages Pfizer to Produce Millions of Doses of hypertension medications treatment.” USA Today. "Expert panel recommends who should be first in line for hypertension medications treatment.

Where will your family be?. " “Fauci says the average American could get vaccinated against hypertension medications as soon as April. 'I would take the treatment.' ” Ohio Gov.

Mike DeWine. €œhypertension medications update. 21-day statewide curfew.” Twin Cities Pioneer Press.

"Mayo Clinic is preparing to start limited hypertension medications vaccinations in December." FDA.gov, letter from Rear Admiral Denise Hinton, chief scientist, June 15, 2020. FDA. €œhypertension medications Update.

FDA’s Ongoing Commitment to Transparency for hypertension medications EUAs.” © 2020 WebMD, LLC. All rights reserved..

Acheter lasix en ligne

When we took the editorship link of acheter lasix en ligne Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main objectives. To promote and embed an evidence-based medicine (EBM) acheter lasix en ligne 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 acheter lasix en ligne been 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 available evidence, the clinical state and circumstances, and patient’s preferences and acheter lasix en ligne 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 quality of studies acheter lasix en ligne 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 …IntroductionQuality-adjusted life years (QALYs) have been increasingly acheter lasix en ligne 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 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 acheter lasix en ligne.

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 generally established.7 8However, the traditional acheter lasix en ligne 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-à-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 acheter lasix en ligne 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 measure onto the generic measure of health in order to enable estimation of acheter lasix en ligne 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 they had missing data in either of the two scales at baseline or at endpoint acheter lasix en ligne.

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, 2=some/moderate problems acheter lasix en ligne or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging acheter lasix en ligne 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 health that they would be acheter lasix en ligne 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 acheter lasix en ligne to minus values=worse than death bounded by −1. 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 included any acheter lasix en ligne validated depression severity measures. The scale scores were converted into the 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 acheter lasix en ligne 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 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 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 acheter lasix en ligne. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then 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 acheter lasix en ligne PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in acheter lasix en ligne 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 (MDD), one only acheter lasix en ligne patients with subthreshold depression and the remaining three included both. All the acheter lasix en ligne studies administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 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 (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient acheter lasix en ligne between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 acheter lasix en ligne shows the same between their change scores.

Table 1 summarises the correspondences between the two scales.PHQ-9 and EQ-5D total acheter lasix en ligne 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 1 PHQ-9 acheter lasix en ligne and EQ-5D total scores at baseline and endpoint.

EQ-5D,Euro-Qol Five Dimensions acheter lasix en ligne. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol Five acheter lasix en ligne Dimensions.

PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 acheter lasix en ligne PHQ-9 change scores and EQ-5D change scores. EQ-5D,Euro-Qol Five acheter lasix en ligne 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 studies28–30 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 values of 0.9–0.8, mild major acheter lasix en ligne depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. 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 acheter lasix en ligne 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 none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 acheter lasix en ligne 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 acheter lasix en ligne 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 acheter lasix en ligne 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 acheter lasix en ligne about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9. The differences in EQ-5D acheter lasix en ligne 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 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, the gain in QALY per year would be equal to 0.05 QALY acheter lasix en ligne. (See figure 3 for acheter lasix en ligne 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 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 acheter lasix en ligne sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments acheter lasix en ligne for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 acheter lasix en ligne 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 while showing slow gradual improvement in both cases, acheter lasix en ligne 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 acheter lasix en ligne 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 that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation acheter lasix en ligne will be similar.

EQ-5D, Euro-Qol Five acheter lasix en ligne Dimensions. PHQ-9, Patient acheter lasix en ligne Health Questionnaire-9. 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 with acheter lasix en ligne 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 acheter lasix en ligne 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 year due to naturalistic improvements to be expected in the control group, the gain in QALY per acheter lasix en ligne year would be equal to 0.05 QALY. Please note that this is acheter lasix en ligne 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 acheter lasix en ligne Dimensions. PHQ-9, PatientHealth acheter lasix en ligne Questionnaire-9. QALY, quality-adjustedlife acheter lasix en ligne years.Several caveats should be considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not acheter lasix en ligne apply to patients with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D 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 acheter lasix en ligne 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 acheter lasix en ligne compare PHQ-9 to EQ-5D-3L only. The EQ-5D-5L, which measures health in five levels instead of three, has been acheter lasix en ligne 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 strengths.

First, our sample included patients with subthreshold depression and acheter lasix en ligne 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 received iCBT or control interventions including care as acheter lasix en ligne 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 impacts, but our estimates, arguably independent of major side effects, acheter lasix en ligne 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 the expense of some potential side effects.Data availability statementData are available acheter lasix en ligne upon reasonable request.

The overall database used for this IPD is restricted due to data sharing agreements with acheter lasix en ligne 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 Evidence-Based Mental Health (EBMH) at the end http://markolewis.com/where-to-get-propecia of lasix 40mg price 2013, we set two main objectives. To promote and embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an lasix 40mg price impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine lasix 40mg price. 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 state lasix 40mg price and circumstances, and patient’s preferences and values.

EBM and EBMH have since lasix 40mg 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 …IntroductionQuality-adjusted life 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 lasix 40mg price 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 lasix 40mg price 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 generally established.7 8However, the traditional focus of measurements lasix 40mg price 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-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the lasix 40mg price 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 measure onto the generic measure of health in order to enable lasix 40mg price 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 they had missing data in lasix 40mg price either of the two scales at baseline or at endpoint.

We excluded studies that focused on lasix 40mg price 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, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from no problem at all in any dimension (11111) to severe problems on all lasix 40mg price 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 health that they would be willing to sacrifice lasix 40mg price for the poor health states as represented by each of the 243 combinations above. The EQ-5D lasix 40mg price scores range between 1=full health and 0=death to minus values=worse than death bounded by −1.

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 lasix 40mg price have been 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, 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 lasix 40mg price 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 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness. The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for lasix 40mg price 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 lasix 40mg price if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then 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 Alzheimer’s disease.14 20–22 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 lasix 40mg price 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 lasix 40mg price included only patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the studies administered EQ-5D-3L lasix 40mg price.

PHQ-9 scores were converted from the BDI-II in three studies24–26 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 lasix 40mg price 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 (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 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 lasix 40mg price their change scores. Table 1 summarises the correspondences between the two lasix 40mg price scales.PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions.

PHQ-9, PatientHealth Questionnaire-9." lasix 40mg price data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five lasix 40mg price Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol lasix 40mg price 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 lasix 40mg price change scores.

EQ-5D,Euro-Qol Five Dimensions lasix 40mg price. 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 studies28–30 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 values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with lasix 40mg price 0.6–0.0. 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, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression lasix 40mg price. 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 lasix 40mg price 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 lasix 40mg price 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 cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically lasix 40mg price 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 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9 lasix 40mg price.

The differences in EQ-5D lasix 40mg price 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 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 lasix 40mg price the control group, the gain in QALY per year would be equal to 0.05 QALY. (See figure lasix 40mg price 3 for 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 1–3 dollars and a 1-year prescription costs US$400–1200 lasix 40mg price dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and should lasix 40mg price 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 may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5 lasix 40mg price. 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 lasix 40mg price 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 year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be lasix 40mg price equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be lasix 40mg price similar. EQ-5D, Euro-Qol lasix 40mg price Five Dimensions. PHQ-9, Patient lasix 40mg price Health Questionnaire-9.

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, lasix 40mg price 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 lasix 40mg price 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 lasix 40mg price 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.

Please note lasix 40mg price 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 lasix 40mg price Dimensions. PHQ-9, PatientHealth lasix 40mg price Questionnaire-9. QALY, quality-adjustedlife lasix 40mg price years.Several caveats should be considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be lasix 40mg price argued that the 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 were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker lasix 40mg price 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 lasix 40mg price 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 lasix 40mg price 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 strengths. First, our sample included patients with subthreshold depression and major depression and from the community or lasix 40mg price workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all lasix 40mg price the patients in our sample received iCBT or control interventions including care as usual. Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive lasix 40mg price 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 of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at lasix 40mg price the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall lasix 40mg price database used for this 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..

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Related Topics Contact Us Submit a Story TipFor years, Ely Bair dealt with migraine headaches, jaw pain and high blood pressure, until a dentist recommended surgery to realign his jaw to get lasix 20mg para que sirve to the root of his health problems. The fix would involve two surgeries over a couple of years and wearing braces on his teeth before and in between the procedures. Bair had the first surgery, on his upper jaw, in 2018 at Swedish Medical Center, First Hill Campus in Seattle.

The surgery was covered by his Premera Blue Cross plan, and Bair’s out-of-pocket hospital lasix 20mg para que sirve expense was $3,000. He changed jobs in 2019 but still had Premera health insurance. In 2020, he had the planned surgery on his lower jaw at the same hospital where he’d been treated the first time.

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The Patient lasix 20mg para que sirve. Ely Bair, 35, a quality assurance analyst. He has a Premera Blue Cross health plan through his job at a biotech firm in Seattle.

Total Bill lasix 20mg para que sirve. Swedish Medical Center billed Bair $27,119 for the second surgery in July 2020. This was Bair’s share of the negotiated rate, after the hospital took $14,310 off the charge.

His insurer lasix 20mg para que sirve paid $5,000. Bair owed additional bills to the surgeon and the anesthesiologist. Service Provider.

Swedish First Hill Campus in lasix 20mg para que sirve Seattle, part of the largest nonprofit health system in the Seattle area, which is affiliated with Providence, a major Catholic health care network. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. What Gives. Bair hit two maddening health system pitfalls here.

He expected his new plan to behave lasix 20mg para que sirve like his previous one from the same insurer — and he expected his mouth to be treated like the rest of his body. Neither commonsense notion appears true in America’s health system. Typically, large companies, such as Bair’s employers, “self insure,” meaning they pay their workers’ health costs but use insurance companies to maintain provider networks and handle claims.

When Bair changed lasix 20mg para que sirve jobs, his insurance coverage changed even though both employers used Premera. Bair paid $3,000 for his first surgery because that was the out-of-pocket maximum under his plan from his previous employer, which covered oral and maxillofacial surgery. Bair expected that using the same hospital and the same insurance carrier would mean his costs would be similar for part two of his treatment.

Bair’s oral and maxillofacial surgeon — the same doctor who performed the first procedure — checked Bair’s benefits through his insurer’s online portal lasix 20mg para que sirve and thought it would be covered. Premera also sent his doctor confirmation agreeing that the second procedure was medically necessary. About three months after the surgery, Bair was shocked to get the large hospital bill — about $24,000 higher than he expected.

When he called lasix 20mg para que sirve Premera, he learned his new plan had a $5,000 lifetime limit on coverage for the reconstructive jaw procedure known as orthognathic surgery, which is sometimes regarded as a dental rather than a medical intervention. His doctor said that information was not noted in Bair’s benefits when the practice reviewed them through an online portal. Premera told Bair he should have known about the limit because it was listed in his detailed, hard-copy, 86-page member-benefit booklet.

The Affordable Care lasix 20mg para que sirve Act in 2014 eliminated lifetime and annual caps on insurance coverage for categories of treatment such as prescription drugs, laboratory services and mental health care. While the ACA lists broad categories about what is considered an “essential health benefit,” each state decides which services are included in each category and the scope or duration that must be offered. Bariatric surgery, physical therapy and abortion are examples of care for which insurance coverage can vary a lot by state under this ACA provision.

Orthognathic surgery is not considered lasix 20mg para que sirve an essential health benefit in Washington. It is sometimes performed for cosmetic purposes only. Also, plans sometimes regard the surgery as part of orthodontia — which frequently involves limits on coverage.

But for Bair, it was a lasix 20mg para que sirve clear medical necessity. Without an ACA requirement for orthognathic surgery, Premera and self-insured plans are allowed to provide various levels of benefits and can impose annual and lifetime caps. Premera spokesperson Courtney Wallace said Bair transferred from a plan with his former company that did not have a lifetime maximum to a plan with a $5,000 lifetime maximum benefit.

Ely Bair had two medically necessary jaw lasix 20mg para que sirve surgeries. For the first, in 2018, his share of the bill was $3,000. For the second, in 2019 after a job change, he was billed $27,000, even though he had the same insurance carrier.(Jovelle Tamayo for KHN) Martine Brousse, a patient advocate and owner of AdvimedPro, which helps patients with health care billing disputes, said Bair acted appropriately by using a doctor and hospital in his health plan’s network and checking with his doctor about his insurance coverage.

She said Swedish should have told him before the surgery — which was planned weeks ahead lasix 20mg para que sirve of time — how much he would have to pay. €œThat is a failure on part of the hospital,” she said. Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms, said it doesn’t seem fair that his first employer covered the cost of his surgery but the second employer did not.

She said the $27,000 lasix 20mg para que sirve bill seemed excessive and the $5,000 lifetime limit very low. €œEssential health benefits serve a really important function, and when there are gaps or holes people can really get hurt,” she said. Resolution.

Bair’s doctor told him the hospital charge was at least three times the amount Swedish charges uninsured patients for the lasix 20mg para que sirve same surgery. Bair said Swedish offered to let him pay the bill over two years but did not make any other concessions. Swedish would not say why it did not verify Bair’s insurance benefits before the surgery or let him know he would face an enormous bill even though he was insured.

€œHospital pricing is complex and nuanced,” Swedish officials said lasix 20mg para que sirve in a statement. Bair’s bill “was inclusive of all the care he received, which included specialized services and expertise, equipment and the operating room time. He had a jaw procedure that had a maximum benefit from his insurer of $5,000.

He was billed the balance not covered by his insurer.” The hospital system said it also has an online lasix 20mg para que sirve tool that generates estimates tailored to patients’ coverage and choice of hospital. The online tool did not come up with anything on the term “orthognathic surgery,” however. Bair appealed three times to Premera to reconsider its decision to cover only $5,000 of the cost of his procedure.

But the insurer rejected each one saying he had exhausted his lifetime orthognathic surgery lasix 20mg para que sirve benefit and he was responsible for any additional care. When Swedish wouldn’t lower his cost, he filed a complaint in December 2020 with the state attorney general’s office. A few months later, Swedish reduced Bair’s bill from over $27,000 to $7,164.

€œBecause neither the patient nor his provider was aware of this limitation in coverage prior to the procedure, the surgeon advocated on lasix 20mg para que sirve the patient’s behalf to get the bill lowered,” the hospital told KHN in a statement. Bair agreed to pay the lower amount. €œThe bill is at least a much more manageable number than the financial ruin $27,000 would have been,” he said.

€œI am just looking forward to closing this chapter and moving on.” His lasix 20mg para que sirve surgeon, who helped him fight the hospital bill and limited insurance coverage, reduced his bill to $5,000 from $10,000, Bair said. Bair said his employer, Adaptive Biotechnologies, is looking into eliminating its $5,000 lifetime limit for the procedure when it is medically necessary. Since the surgery, Bair said he gets far fewer migraine headaches and his high blood pressure has been reduced.

€œI feel way lasix 20mg para que sirve more energized,” he said. The Takeaway. When facing a planned surgery, talk to your hospital, doctor and insurer about how much of the bill you will be responsible for — and get it in writing before any procedure.

“In theory, you should be able to rely on lasix 20mg para que sirve your provider to confirm your coverage but, in practice, it is in your best interest to call your insurer yourself,” Corlette said. Even though the ACA eliminated lifetime and annual caps on coverage, that applies only to services deemed essential in a patient’s state. Be aware that certain surgeries — like jaw surgery — lie in a gray area.

Insurers might lasix 20mg para que sirve not consider them a necessary medical intervention or even a medical procedure at all. Corlette said health plans should notify patients when they are closing in on lifetime or annual limits, but that doesn’t always happen. Also, be aware that even though your insurance carrier may stay the same after switching jobs, your benefits could be quite different.

Kudos to Bair for being a proactive patient and appealing to the state attorney general — which got him lasix 20mg para que sirve a positive result. Stephanie O’Neill contributed the audio profile with this report. Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills.

Do you have an interesting medical bill you want to share with us?.

KHN Midwest http://spinslotsdeals.com/can-you-buy-zithromax-over-the-counter-in-canada/ correspondent Cara Anthony talked about hypertension medications treatments on Illinois lasix 40mg price Public Media’s “The 21st Show” on Monday. Related Topics Contact Us Submit a Story TipFor years, Ely Bair dealt with migraine headaches, jaw pain and high blood pressure, until a dentist recommended surgery to realign his jaw to get to the root of his health problems. The fix would involve two surgeries over a couple of years and wearing braces on his teeth before and in between the procedures.

Bair had the first surgery, on his upper jaw, in 2018 at Swedish Medical lasix 40mg price Center, First Hill Campus in Seattle. The surgery was covered by his Premera Blue Cross plan, and Bair’s out-of-pocket hospital expense was $3,000. He changed jobs in 2019 but still had Premera health insurance.

In 2020, he had the planned surgery on his lower jaw at the same hospital where he’d lasix 40mg price been treated the first time. The surgery went well, and he spent one night in the hospital before being discharged. He was healing well and beginning to see the benefits of the surgeries.

Then the bill lasix 40mg price arrived. The Patient. Ely Bair, 35, a quality assurance analyst.

He has a Premera Blue Cross health plan through his lasix 40mg price job at a biotech firm in Seattle. Total Bill. Swedish Medical Center billed Bair $27,119 for the second surgery in July 2020.

This was Bair’s share of the negotiated rate, after the hospital took $14,310 lasix 40mg price off the charge. His insurer paid $5,000. Bair owed additional bills to the surgeon and the anesthesiologist.

Service Provider lasix 40mg price. Swedish First Hill Campus in Seattle, part of the largest nonprofit health system in the Seattle area, which is affiliated with Providence, a major Catholic health care network. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. What Gives.

Bair hit two maddening health lasix 40mg price system pitfalls here. He expected his new plan to behave like his previous one from the same insurer — and he expected his mouth to be treated like the rest of his body. Neither commonsense notion appears true in America’s health system.

Typically, large companies, such as Bair’s employers, lasix 40mg price “self insure,” meaning they pay their workers’ health costs but use insurance companies to maintain provider networks and handle claims. When Bair changed jobs, his insurance coverage changed even though both employers used Premera. Bair paid $3,000 for his first surgery because that was the out-of-pocket maximum under his plan from his previous employer, which covered oral and maxillofacial surgery.

Bair expected that lasix 40mg price using the same hospital and the same insurance carrier would mean his costs would be similar for part two of his treatment. Bair’s oral and maxillofacial surgeon — the same doctor who performed the first procedure — checked Bair’s benefits through his insurer’s online portal and thought it would be covered. Premera also sent his doctor confirmation agreeing that the second procedure was medically necessary.

About three months after the surgery, Bair lasix 40mg price was shocked to get the large hospital bill — about $24,000 higher than he expected. When he called Premera, he learned his new plan had a $5,000 lifetime limit on coverage for the reconstructive jaw procedure known as orthognathic surgery, which is sometimes regarded as a dental rather than a medical intervention. His doctor said that information was not noted in Bair’s benefits when the practice reviewed them through an online portal.

Premera told Bair he should have known lasix 40mg price about the limit because it was listed in his detailed, hard-copy, 86-page member-benefit booklet. The Affordable Care Act in 2014 eliminated lifetime and annual caps on insurance coverage for categories of treatment such as prescription drugs, laboratory services and mental health care. While the ACA lists broad categories about what is considered an “essential health benefit,” each state decides which services are included in each category and the scope or duration that must be offered.

Bariatric surgery, physical lasix 40mg price therapy and abortion are examples of care for which insurance coverage can vary a lot by state under this ACA provision. Orthognathic surgery is not considered an essential health benefit in Washington. It is sometimes performed for cosmetic purposes only.

Also, plans sometimes regard lasix 40mg price the surgery as part of orthodontia — which frequently involves limits on coverage. But for Bair, it was a clear medical necessity. Without an ACA requirement for orthognathic surgery, Premera and self-insured plans are allowed to provide various levels of benefits and can impose annual and lifetime caps.

Premera spokesperson Courtney Wallace said Bair transferred from a plan with his former company that did not have a lifetime maximum to a plan lasix 40mg price with a $5,000 lifetime maximum benefit. Ely Bair had two medically necessary jaw surgeries. For the first, in 2018, his share of the bill was $3,000.

For the second, in 2019 after a job change, he was billed $27,000, even though he had the same insurance carrier.(Jovelle Tamayo for KHN) Martine Brousse, a patient advocate and owner of AdvimedPro, which helps patients with health care billing disputes, said Bair acted appropriately by using a doctor and hospital in his health plan’s network and checking with his doctor about his lasix 40mg price insurance coverage. She said Swedish should have told him before the surgery — which was planned weeks ahead of time — how much he would have to pay. €œThat is a failure on part of the hospital,” she said.

Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms, said it doesn’t lasix 40mg price seem fair that his first employer covered the cost of his surgery but the second employer did not. She said the $27,000 bill seemed excessive and the $5,000 lifetime limit very low. €œEssential health benefits serve a really important function, and when there are gaps or holes people can really get hurt,” she said.

Resolution. Bair’s doctor told him the hospital charge was at least three times the amount Swedish charges uninsured patients for the same surgery. Bair said Swedish offered to let him pay the bill over two years but did not make any other concessions.

Swedish would not say why it did not verify Bair’s insurance benefits before the surgery or let him know he would face an enormous bill even though he was insured. €œHospital pricing is complex and nuanced,” Swedish officials said in a statement. Bair’s bill “was inclusive of all the care he received, which included specialized services and expertise, equipment and the operating room time.

He had a jaw procedure that had a maximum benefit from his insurer of $5,000. He was billed the balance not covered by his insurer.” The hospital system said it also has an online tool that generates estimates tailored to patients’ coverage and choice of hospital. The online tool did not come up with anything on the term “orthognathic surgery,” however.

Bair appealed three times to Premera to reconsider its decision to cover only $5,000 of the cost of his procedure. But the insurer rejected each one saying he had exhausted his lifetime orthognathic surgery benefit and he was responsible for any additional care. When Swedish wouldn’t lower his cost, he filed a complaint in December 2020 with the state attorney general’s office.

A few months later, Swedish reduced Bair’s bill from over $27,000 to $7,164. €œBecause neither the patient nor his provider was aware of this limitation in coverage prior to the procedure, the surgeon advocated on the patient’s behalf to get the bill lowered,” the hospital told KHN in a statement. Bair agreed to pay the lower amount.

€œThe bill is at least a much more manageable number than the financial ruin $27,000 would have been,” he said. €œI am just looking forward to closing this chapter and moving on.” His surgeon, who helped him fight the hospital bill and limited insurance coverage, reduced his bill to $5,000 from $10,000, Bair said. Bair said his employer, Adaptive Biotechnologies, is looking into eliminating its $5,000 lifetime limit for the procedure when it is medically necessary.

Since the surgery, Bair said he gets far fewer migraine headaches and his high blood pressure has been reduced. €œI feel way more energized,” he said. The Takeaway.

When facing a planned surgery, talk to your hospital, doctor and insurer about how much of the bill you will be responsible for — and get it in writing before any procedure. “In theory, you should be able to rely on your provider to confirm your coverage but, in practice, it is in your best interest to call your insurer yourself,” Corlette said. Even though the ACA eliminated lifetime and annual caps on coverage, that applies only to services deemed essential in a patient’s state.

Be aware that certain surgeries — like jaw surgery — lie in a gray area. Insurers might not consider them a necessary medical intervention or even a medical procedure at all. Corlette said health plans should notify patients when they are closing in on lifetime or annual limits, but that doesn’t always happen.

Also, be aware that even though your insurance carrier may stay the same after switching jobs, your benefits could be quite different. Kudos to Bair for being a proactive patient and appealing to the state attorney general — which got him a positive result. Stephanie O’Neill contributed the audio profile with this report.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us?. Tell us about it!.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Does lasix cause kidney failure

1. 13 ADM-04 - Medicaid Application and Renewal Processing for Modified Adjusted Gross Income (MAGI) Eligibility Groups (Dec. 4, 2013) PDF Links to the appendix (which is just a list of the attachments) and ten attachments that accompany it available a.

Http://www.health.ny.gov/health_care/medicaid/publications/pub2013adm.htm "This ADM advises local districts of the referral process for applicants in a Modified Adjusted Gross Income (MAGI) eligibility group to New York State of Health (NYSOH), New York’s Health Insurance Marketplace, and the requirements for determining or renewing Medicaid eligibility for certain individuals using MAGI-like budgeting rules. This directive also informs districts of the actions the State will take to transition Family Health Plus (FHPlus) Single Individuals and Childless Couples to coverage under the Affordable Care Act (ACA) effective January 1, 2014, and advises districts of special instructions for processing Medicaid referrals from NYSOH for coverage/payment of medical bills in the three-month retroactive period.” NYC HRA has also issued a directive re applications procedures - see Important Changes in Medicaid Application Submissions -MAGI and Non-MAGI (Dec. 24, 2013) 2.

13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) This directive outlines the changes to Medicaid eligibility that become effective January 1, 2014 under the ACA. 13 ADM-03 describes "expanded Medicaid coverage under the ACA, a new method for counting household income based on modified adjusted gross income (MAGI), Medicaid benefits under the ACA and Medicaid enrollment in New York's Health Benefit Exchange." The directive contains several attachments, including these desk aids explaining - MAGI Eligibility Groups and Income Levels (Attachment 1) - MAGI and Non-MAGI Eligibility Groups (Attachment 2) and - the notice to households whose applications are being referred to the local district for non-MAGI processing. (Attachment 3) 3.

GIS 13 MA/021 Renewal Processing for MAGI Eligibility Groups Beginning January 2014 (PDF) (11/15/2013) 4. GIS 13/MA/022 2014 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards PDF Attachment 1 - Annual and monthly income and resource limits for "non-MAGI" population - Attachment 2 - Explains what income limits -- usually a percentage of the Federal Poverty Level -- apply to different categories of people, for use with Attachment 1 of same GIS. 5.

GIS 14/MA-007 Update on Self-Employment Policy for MAGI-like Budgeting (3/21/2014) 6. GIS 14 MA/016. Long Term Care Eligibility Rules and Estate Recovery Provisions for MAGI Individuals 7.

GIS 14 MA/022 - Medicaid Eligibility for Pregnant Minors PDF (7/1/2014) 8. 2014 LCM-02 - Medicaid Recipients Transferred at Renewal from New York State of Health to Local Departments of Social Services (Dec. 1, 2014) 9.

GIS 15 MA/008 - Treatment of Income of Dependents Under MAGI-like Rules (4/9/2015) Child's Social Security or other income may be disregarded from household income, depending on amount and type of income. UPDATED 2018 - click here 10. GIS 15 MA/022 - Continuous Coverage for MAGI Individuals (12/23/15) PDF Attachment 1 Announces that beginning January 1, 2016, 12-month continuous coverage protections will no longer be extended to MAGI recipients who turn 65.

Clarifies that "MAGI-like" category -- those who fall into a MAGI category but are getting their Medicaid coverage through their LDSS or HRA -- are entitled to the same 12-month continuous coverage protections as MAGIs (people who fall into a MAGI category and are getting their coverage through the Marketplace). Some people must get coverage through their LDSS because they need long term care such as home care, a waiver program, or nursing home care. They are eligible for these services with MAGI eligibility- see GIS 14 MA/016 above- but need eligibility processed by the local district.

11. GIS 15 MA/020 - IRS Tax Form 1095-B Guidance PDF Attachment 1 Attachment 2 Explains form sent to MAGI Medicaid recipients to prove they are enrolled in Medicaid so they are not charged with a tax penalty charged to those who did not enroll in a health insurance plan - under the ACA 12. 2016 LCM-01 - Transitioning MAGI Consumers from WMS to NY State of Health - attachments at this link 13.

16 ADM-01 - Transitioning Essential Plan Consumers from WMS to NY State of Health PDF -- read more about the Essential Plan here 14. GIS 16 MA/004 -Referrals from NY State of Health to Local Departments of Social Services for Individuals who Turn Age 65 and Instructions for Referrals for Essential Plan Consumers (PDF) -- read more about the Essential Plan here 15. GIS 17 MA/011.

Treatment of Federal Income Tax Refunds and Advanced Payments PDF 17. GIS 19 MA/11 – Changes to Countable Income for Modified Adjusted Gross Income (MAGI) Based Eligibility Determinations (PDF) Alimony changes - how treated under MAGI rules. Alimony received under a divorce or separation agreement finalized AFTER 12/31/2018 NOT countable as income.

If finalized BEFORE that date it IS countable as income. Alimony PAID under agreement finalized before 12/31/18 is deductible from income. If paid under agreement finalized after that date, it IS NOT deductible from income.

Lottery and Gambling winnings - if over $80,000, now countable as income over several months or years depending on amount received. Countable solely for the individual who received the winnings. The NHeLP Advocates Guide to MAGI (updated 2018) has more info about the changes in how lottery winnings are treated under changes enacted in 2018.

The changes are meant to disqualify winners from MAGI by creating an exception to the rules that normally exempt non-recurring lump sums. See more about lump sums in the SNT outline posted in this article. Also view webinars on Lump Sum impact on benefits, including MAGI Medicaid.

Attachment (PDF) List of Non-Taxable Income Sources Excluded from Gross Income for MAGIBudgeting," (corrects and amends attachmentpreviously distributed as Attachment IV to 13 ADM-04) 18. 2021-09-27 Transition some MAGI-Like cases DSS/HRA to NYSofHealth NYC Medicaid Alert. Transitioning of MAGI-Like Medicaid Cases from DSS/HRA Medicaid to NY State of Health Exchange.

Since the New York State of Health was introduced in 2014, it has been responsible for all MAGI Medicaid cases. However, there were many Medicaid consumers with MAGI-like budgeting who were found eligible before January 1st, 2014. Their cases have remained with HRA until they could be transitioned.

Those consumers were to be transitioned in phases and the first transition began in June 2018. NYS has resumed the transition and approx. 158,600 individuals transitioned between April 2021 through July 2021.

The alert details which groups of MAGI recipients were transitioned and those who will not be transitioned. Clients will not be required to renew their coverage in NYSOH until after the hypertension medications Health Emergency ends. This site provides general information only.

This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship.

To contact a lawyer, visit http://lawhelp.org/ny. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information.

To report a dead link or other website-related problem, please e-mail us.NYS updated the 2021 levels with GIS 21 MA/06 -with the 2021 Federal Poverty Levels (April 2021) Here is the 2021 HRA Income and Resources Level Chart Non-MAGI - 2021 Disabled, 65+ or Blind ("DAB" or SSI-Related) and have Medicare MAGI (2021)* (<. 65, Does not have Medicare)(OR has Medicare and has dependent child <. 18 or <.

19 in school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN* For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $884 (up from $875 in 2020) $1300 (up from $1,284 in 2020) $1,482 $2,004 $2,526 $2,146 $2,903 Resources $15,900 (up from $15,750 in 2020) $23,400 (up from $23,100 in 2020) NO LIMIT** NO LIMIT 2020 levels are in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates and attachments here * MAGI and ESSENTIAL plan levels are based on Federal Poverty Levels, which are not released until later in 2021.

2020 levels are used until then. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. WHAT IS THE HOUSEHOLD SIZE?.

See rules here. HOW TO READ THE HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school.

42 C.F.R. § 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <.

Age 1, 154% FPL for children age 1 - 19. CAUTION. What is counted as income may not be what you think.

For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes.

GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.

There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules HOW TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person.

HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size.

People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.

Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.

See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION.

Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.

Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.

This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL.

Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.

For newest lasix 40mg price visit their website directives scroll to the bottom of this page. 1. 13 ADM-04 - Medicaid Application and Renewal Processing for Modified Adjusted Gross Income (MAGI) Eligibility Groups (Dec. 4, 2013) PDF Links to the appendix lasix 40mg price (which is just a list of the attachments) and ten attachments that accompany it available a.

Http://www.health.ny.gov/health_care/medicaid/publications/pub2013adm.htm "This ADM advises local districts of the referral process for applicants in a Modified Adjusted Gross Income (MAGI) eligibility group to New York State of Health (NYSOH), New York’s Health Insurance Marketplace, and the requirements for determining or renewing Medicaid eligibility for certain individuals using MAGI-like budgeting rules. This directive also informs districts of the actions the State will take to transition Family Health Plus (FHPlus) Single Individuals and Childless Couples to coverage under the Affordable Care Act (ACA) effective January 1, 2014, and advises districts of special instructions for processing Medicaid referrals from NYSOH for coverage/payment of medical bills in the three-month retroactive period.” NYC HRA has also issued a directive re applications procedures - see Important Changes in Medicaid Application Submissions -MAGI and Non-MAGI (Dec. 24, 2013) 2 lasix 40mg price. 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) This directive outlines the changes to Medicaid eligibility that become effective January 1, 2014 under the ACA.

13 ADM-03 describes "expanded Medicaid coverage under the ACA, a new method for counting household income based on modified adjusted gross income (MAGI), Medicaid benefits under the ACA and Medicaid enrollment in New York's Health Benefit Exchange." The directive contains several attachments, including these desk aids explaining - MAGI Eligibility Groups and Income Levels (Attachment 1) - MAGI and Non-MAGI Eligibility Groups (Attachment 2) and - the notice to households whose applications are being referred to the local district for non-MAGI processing. (Attachment 3) lasix 40mg price 3. GIS 13 MA/021 Renewal Processing for MAGI Eligibility Groups Beginning January 2014 (PDF) (11/15/2013) 4. GIS 13/MA/022 2014 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards PDF Attachment 1 - Annual and monthly income and resource limits for "non-MAGI" population - Attachment 2 - Explains what income limits -- usually a percentage of the Federal Poverty Level -- apply to different categories of people, for use with Attachment 1 of same GIS.

5. GIS 14/MA-007 Update on Self-Employment Policy for MAGI-like Budgeting (3/21/2014) 6. GIS 14 MA/016. Long Term Care Eligibility Rules and Estate Recovery Provisions for MAGI Individuals 7.

GIS 14 MA/022 - Medicaid Eligibility for Pregnant Minors PDF (7/1/2014) 8. 2014 LCM-02 - Medicaid Recipients Transferred at Renewal from New York State of Health to Local Departments of Social Services (Dec. 1, 2014) 9. GIS 15 MA/008 - Treatment of Income of Dependents Under MAGI-like Rules (4/9/2015) Child's Social Security or other income may be disregarded from household income, depending on amount and type of income.

UPDATED 2018 - click here 10. GIS 15 MA/022 - Continuous Coverage for MAGI Individuals (12/23/15) PDF Attachment 1 Announces that beginning January 1, 2016, 12-month continuous coverage protections will no longer be extended to MAGI recipients who turn 65. Clarifies that "MAGI-like" category -- those who fall into a MAGI category but are getting their Medicaid coverage through their LDSS or HRA -- are entitled to the same 12-month continuous coverage protections as MAGIs (people who fall into a MAGI category and are getting their coverage through the Marketplace). Some people must get coverage through their LDSS because they need long term care such as home care, a waiver program, or nursing home care.

They are eligible for these services with MAGI eligibility- see GIS 14 MA/016 above- but need eligibility processed by the local district. 11. GIS 15 MA/020 - IRS Tax Form 1095-B Guidance PDF Attachment 1 Attachment 2 Explains form sent to MAGI Medicaid recipients to prove they are enrolled in Medicaid so they are not charged with a tax penalty charged to those who did not enroll in a health insurance plan - under the ACA 12. 2016 LCM-01 - Transitioning MAGI Consumers from WMS to NY State of Health - attachments at this link 13.

16 ADM-01 - Transitioning Essential Plan Consumers from WMS to NY State of Health PDF -- read more about the Essential Plan here 14. GIS 16 MA/004 -Referrals from NY State of Health to Local Departments of Social Services for Individuals who Turn Age 65 and Instructions for Referrals for Essential Plan Consumers (PDF) -- read more about the Essential Plan here 15. GIS 17 MA/011. Treatment of Federal Income Tax Refunds and Advanced Payments PDF 17.

GIS 19 MA/11 – Changes to Countable Income for Modified Adjusted Gross Income (MAGI) Based Eligibility Determinations (PDF) Alimony changes - how treated under MAGI rules. Alimony received under a divorce or separation agreement finalized AFTER 12/31/2018 NOT countable as income. If finalized BEFORE that date it IS countable as income. Alimony PAID under agreement finalized before 12/31/18 is deductible from income.

If paid under agreement finalized after that date, it IS NOT deductible from income. Lottery and Gambling winnings - if over $80,000, now countable as income over several months or years depending on amount received. Countable solely for the individual who received the winnings. The NHeLP Advocates Guide to MAGI (updated 2018) has more info about the changes in how lottery winnings are treated under changes enacted in 2018.

The changes are meant to disqualify winners from MAGI by creating an exception to the rules that normally exempt non-recurring lump sums. See more about lump sums in the SNT outline posted in this article. Also view webinars on Lump Sum impact on benefits, including MAGI Medicaid. Attachment (PDF) List of Non-Taxable Income Sources Excluded from Gross Income for MAGIBudgeting," (corrects and amends attachmentpreviously distributed as Attachment IV to 13 ADM-04) 18.

2021-09-27 Transition some MAGI-Like cases DSS/HRA to NYSofHealth NYC Medicaid Alert. Transitioning of MAGI-Like Medicaid Cases from DSS/HRA Medicaid to NY State of Health Exchange. Since the New York State of Health was introduced in 2014, it has been responsible for all MAGI Medicaid cases. However, there were many Medicaid consumers with MAGI-like budgeting who were found eligible before January 1st, 2014.

Their cases have remained with HRA until they could be transitioned. Those consumers were to be transitioned in phases and the first transition began in June 2018. NYS has resumed the transition and approx. 158,600 individuals transitioned between April 2021 through July 2021.

The alert details which groups of MAGI recipients were transitioned and those who will not be transitioned. Clients will not be required to renew their coverage in NYSOH until after the hypertension medications Health Emergency ends. This site provides general information only. This is not legal advice.

You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelp.org/ny. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law.

However, we do not guarantee the accuracy of this information. To report a dead link or other website-related problem, please e-mail us.NYS updated the 2021 levels with GIS 21 MA/06 -with the 2021 Federal Poverty Levels (April 2021) Here is the 2021 HRA Income and Resources Level Chart Non-MAGI - 2021 Disabled, 65+ or Blind ("DAB" or SSI-Related) and have Medicare MAGI (2021)* (<. 65, Does not have Medicare)(OR has Medicare and has dependent child <. 18 or <.

19 in school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN* For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $884 (up from $875 in 2020) $1300 (up from $1,284 in 2020) $1,482 $2,004 $2,526 $2,146 $2,903 Resources $15,900 (up from $15,750 in 2020) $23,400 (up from $23,100 in 2020) NO LIMIT** NO LIMIT 2020 levels are in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates and attachments here * MAGI and ESSENTIAL plan levels are based on Federal Poverty Levels, which are not released until later in 2021. 2020 levels are used until then.

NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. WHAT IS THE HOUSEHOLD SIZE?. See rules here. HOW TO READ THE HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels.

Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school.

42 C.F.R. § 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, 154% FPL for children age 1 - 19.

CAUTION. What is counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).

There are good changes and bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.

There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules HOW TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical.

There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article.

Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.

See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility.

See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.

This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL.

This has now been folded into the new MAGI adult group whose limit is 138% FPL.