A correspondence letter published in the New England Journal of Medicine suggests that pulse oximeters â frequently used in remote patient monitoring â may show misleading readings for Black patients can you buy levitra without a prescription. Researchers led by Dr. Michael W can you buy levitra without a prescription. Sjoding at the University of Michigan Medical School compared measurements of arterial oxygen saturation with pulse oximetry.They found that in two large cohorts, Black patients had nearly three times the frequency of occult hypoxemia â meaning there was a disconnect between their arterial oxygen saturation and their pulse oximetry â compared to white patients. HIMSS20 Digital Learn on-demand, earn credit, can you buy levitra without a prescription find products and solutions.
Get Started >>. "Given the widespread use of pulse oximetry for medical decision making, these findings have some major implications, especially during the current erectile dysfunction treatment levitra," wrote the researchers. WHY IT MATTERS Pulse oximeters are frequently used in order to triage patients and to monitor individuals with erectile dysfunction treatment, especially as part of a larger can you buy levitra without a prescription remote patient monitoring ecosystem. For this study, Sjoding and colleagues analyzed 10,789 pairs of measures of oxygen saturation from 276 Black patients and 1,333 white ones in a cohort from the University of Michigan. And 37,308 can you buy levitra without a prescription pairs obtained from 1,050 Black patients and 7,342 white ones in a multicenter cohort.
In the first cohort, among patients who showed 92-96% oxygen saturation on pulse oximetry, 11.7% of arterial oxygen saturation measurements from Black patients were at less than 88%, compared with 3.6% of white patient measurements. In the multicenter cohort, 17% of arterial blood gas oxygen saturation measurements among Black patients were at less than 88%, despite saturation measurements of 92-96% on pulse oximeters â compared with 6.2% of measurements among white patients. "It is important to note that can you buy levitra without a prescription not all Black patients who had a pulse oximetry value of 92 to 96% had occult hypoxemia," wrote the researchers. "However, the variation in risk according to race necessitates the integration of pulse oximetry with other clinical and patient-reported data.â The NEJM letter did not elaborate as to the manufacturer of the pulse oximeters or whether they were part of a connected device environment. It did note, however, that questions can you buy levitra without a prescription about their technology have been raised in the context of reproducing racial bias.THE LARGER TRENDThe question of addressing bias in the datasets used to train medical devices has arisen multiple times in recent months, with panelists at the HIMSS &.
Health 2.0 Europe Digital Conference noting that dermatological diagnostic apps trained on mostly white patients could be less accurate among patients with darker skin. This is of even greater importance amidst the erectile dysfunction treatment crisis, which has seen stretched-thin hospitals and health systems monitor patients from afar with the help of peripherals such as thermometers and pulse oximeters. ON THE RECORD "Oxygen is among the most frequently administered can you buy levitra without a prescription medical therapies, with a level that is commonly adjusted according to the reading on a pulse oximeter that measures patientsâ oxygen saturation," wrote the researchers. "Our results suggest that reliance on pulse oximetry to triage patients and adjust supplemental oxygen levels may place Black patients at increased risk for hypoxemia," they continued. Kat Jercich is senior editor of Healthcare IT News.Twitter.
@kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication..
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In places where most people wore masks, those who did get infected seemed dramatically less likely to get severely ill compared to places with less mask-wearing.It seems people get less sick if they wear a mask.When you wear a mask – levitra ed even a cloth mask – you typically are exposed to a lower dose of the erectile dysfunction than if you didn’t. Both recent experiments in animal models using erectile dysfunction and nearly a hundred years of viral research show that lower viral doses usually means less severe disease.No mask is perfect, and wearing one might not prevent you from getting infected. But it might be the difference between a case of erectile dysfunction treatment that sends you to the hospital and a case so mild levitra ed you don’t even realize you’re infected.Exposure Dose Determines Severity of DiseaseWhen you breathe in a respiratory levitra, it immediately begins hijacking any cells it lands near to turn them into levitra production machines. The immune system tries to stop this process to halt the spread of the levitra.The amount of levitra that you’re exposed to – called the viral inoculum, or dose – has a lot to do with how sick you get. If the exposure dose is levitra ed very high, the immune response can become overwhelmed.
Between the levitra taking over huge numbers of cells and the immune system’s drastic efforts to contain the , a lot of damage is done to the body and a person can become very sick.On the other hand, if the initial dose of the levitra is small, the immune system is able to contain the levitra with less drastic measures. If this happens, the person experiences fewer symptoms, if any.This concept of viral dose being related to disease severity levitra ed has been around for almost a century. Many animal studies have shown that the higher the dose of a levitra you give an animal, the more sick it becomes. In 2015, researchers tested this concept in human volunteers using a nonlethal flu levitra ed levitra and found the same result. The higher the flu levitra dose given to the volunteers, the sicker they became.In July, researchers published a paper showing that viral dose was related to disease severity in hamsters exposed to the erectile dysfunction.
Hamsters who were given a higher viral dose got more sick than hamsters given a lower dose.Based on this body levitra ed of research, it seems very likely that if you are exposed to erectile dysfunction, the lower the dose, the less sick you will get.So what can a person do to lower the exposure dose?. Masks Reduce Viral DoseMost infectious disease researchers and epidemiologists believe that the erectile dysfunction is mostly spread levitra ed by airborne droplets and, to a lesser extent, tiny aerosols. Research shows that both cloth and surgical masks can block the majority of particles that could contain erectile dysfunction. While no levitra ed mask is perfect, the goal is not to block all of the levitra, but simply reduce the amount that you might inhale. Almost any mask will successfully block some amount.Laboratory experiments have shown that good cloth masks and surgical masks could block at least 80% of viral particles from entering your nose and mouth.
Those particles and other contaminants will get trapped in the fibers of the mask, so the CDC recommends washing your cloth mask after each use if possible.The final piece of experimental evidence showing that masks reduce viral levitra ed dose comes from another hamster experiment. Hamsters were divided into an unmasked group and a masked group by placing surgical mask material over the pipes that brought air into the cages of the masked group. Hamsters infected with the erectile dysfunction were placed in cages next to levitra ed the masked and unmasked hamsters, and air was pumped from the infected cages into the cages with uninfected hamsters.As expected, the masked hamsters were less likely to get infected with erectile dysfunction treatment. But when some of the masked hamsters did get infected, they had more mild disease than the unmasked hamsters.Masks Increase Rate of Asymptomatic CasesIn July, the CDC estimated that around 40% of people infected with erectile dysfunction are asymptomatic, and a number of other studies have confirmed this number.However, in places where everyone wears masks, the rate of asymptomatic seems to be much higher. In an outbreak on an Australian cruise ship called the Greg Mortimer in late March, the passengers were all given surgical masks and the staff were levitra ed given N95 masks after the first case of erectile dysfunction treatment was identified.
Mask usage was apparently very high, and even though 128 of the 217 passengers and staff eventually tested positive for the erectile dysfunction, 81% of the infected people remained asymptomatic.Further evidence has come from two more recent outbreaks, the first at a seafood processing plant in Oregon and the second at a chicken processing plant in Arkansas. In both places, the workers were levitra ed provided masks and required to wear them at all times. In the outbreaks from both plants, nearly 95% of infected people were asymptomatic.There is no doubt that universal mask wearing slows the spread of the erectile dysfunction. My colleagues and I believe that evidence from laboratory experiments, case studies like the cruise ship and food processing plant outbreaks and long-known biological principles make a strong case that masks protect the wearer too.The goal of any tool to fight this levitra is to slow levitra ed the spread of the levitra and save lives. Universal masking will do both.Monica Gandhi is a Professor of Medicine with the Division of HIV, Infectious Diseases and Global Medicine at the University of California, San Francisco.
This article originally appeared on The Conversation levitra ed and is republished under a Creative Commons license. Read the original here..
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As governments and workplaces began to recommend or mandate mask wearing, my colleagues and I noticed an interesting trend. In places where most people wore masks, those who did get infected seemed dramatically less likely to get severely ill compared to places with less mask-wearing.It seems people get less sick if they wear a mask.When you wear a mask – even a cloth mask – you typically are can you buy levitra without a prescription exposed to a lower dose of the erectile dysfunction than if you didn’t. Both recent experiments in animal models using erectile dysfunction and nearly a hundred years of viral research show that lower viral doses usually means less severe disease.No mask is perfect, and wearing one might not prevent you from getting infected. But it might be the difference between a case of erectile dysfunction treatment that sends you to the hospital and a case so mild you don’t even can you buy levitra without a prescription realize you’re infected.Exposure Dose Determines Severity of DiseaseWhen you breathe in a respiratory levitra, it immediately begins hijacking any cells it lands near to turn them into levitra production machines.
The immune system tries to stop this process to halt the spread of the levitra.The amount of levitra that you’re exposed to – called the viral inoculum, or dose – has a lot to do with how sick you get. If the exposure dose is very high, the immune response can become can you buy levitra without a prescription overwhelmed. Between the levitra taking over huge numbers of cells and the immune system’s drastic efforts to contain the , a lot of damage is done to the body and a person can become very sick.On the other hand, if the initial dose of the levitra is small, the immune system is able to contain the levitra with less drastic measures. If this happens, the person experiences fewer can you buy levitra without a prescription symptoms, if any.This concept of viral dose being related to disease severity has been around for almost a century.
Many animal studies have shown that the higher the dose of a levitra you give an animal, the more sick it becomes. In 2015, researchers tested this concept in human volunteers using a nonlethal flu levitra and found the same can you buy levitra without a prescription result. The higher the flu levitra dose given to the volunteers, the sicker they became.In July, researchers published a paper showing that viral dose was related to disease severity in hamsters exposed to the erectile dysfunction. Hamsters who were given a higher viral dose got more sick than hamsters given a lower dose.Based on this body of research, it seems very likely that if you are exposed to erectile dysfunction, the lower the dose, the less sick you will get.So what can a person do to lower can you buy levitra without a prescription the exposure dose?.
Masks Reduce Viral DoseMost can you buy levitra without a prescription infectious disease researchers and epidemiologists believe that the erectile dysfunction is mostly spread by airborne droplets and, to a lesser extent, tiny aerosols. Research shows that both cloth and surgical masks can block the majority of particles that could contain erectile dysfunction. While no mask is perfect, the goal is can you buy levitra without a prescription not to block all of the levitra, but simply reduce the amount that you might inhale. Almost any mask will successfully block some amount.Laboratory experiments have shown that good cloth masks and surgical masks could block at least 80% of viral particles from entering your nose and mouth.
Those particles and other contaminants will get trapped in the fibers of the mask, so the CDC recommends washing your cloth mask after each use if possible.The final piece of experimental evidence showing that masks reduce viral dose can you buy levitra without a prescription comes from another hamster experiment. Hamsters were divided into an unmasked group and a masked group by placing surgical mask material over the pipes that brought air into the cages of the masked group. Hamsters infected with the erectile dysfunction were placed in cages next to the masked and unmasked hamsters, and air was pumped from the infected cages into the cages with uninfected hamsters.As expected, the masked can you buy levitra without a prescription hamsters were less likely to get infected with erectile dysfunction treatment. But when some of the masked hamsters did get infected, they had more mild disease than the unmasked hamsters.Masks Increase Rate of Asymptomatic CasesIn July, the CDC estimated that around 40% of people infected with erectile dysfunction are asymptomatic, and a number of other studies have confirmed this number.However, in places where everyone wears masks, the rate of asymptomatic seems to be much higher.
In an outbreak on an Australian cruise ship called the Greg Mortimer in late March, the passengers were all given surgical masks and the staff were given N95 can you buy levitra without a prescription masks after the first case of erectile dysfunction treatment was identified. Mask usage was apparently very high, and even though 128 of the 217 passengers and staff eventually tested positive for the erectile dysfunction, 81% of the infected people remained asymptomatic.Further evidence has come from two more recent outbreaks, the first at a seafood processing plant in Oregon and the second at a chicken processing plant in Arkansas. In both can you buy levitra without a prescription places, the workers were provided masks and required to wear them at all times. In the outbreaks from both plants, nearly 95% of infected people were asymptomatic.There is no doubt that universal mask wearing slows the spread of the erectile dysfunction.
My colleagues and I believe that evidence from laboratory experiments, can you buy levitra without a prescription case studies like the cruise ship and food processing plant outbreaks and long-known biological principles make a strong case that masks protect the wearer too.The goal of any tool to fight this levitra is to slow the spread of the levitra and save lives. Universal masking will do both.Monica Gandhi is a Professor of Medicine with the Division of HIV, Infectious Diseases and Global Medicine at the University of California, San Francisco. This article originally appeared on The Conversation and is can you buy levitra without a prescription republished under a Creative Commons license. Read the original here..
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When the erectile dysfunction viagra cialis and levitra all 80 off hit Martha Lelandâs Connecticut nursing home last year, she and dozens of other residents contracted the disease while the facility was on lockdown. Twenty-eight residents died, including her roommate. âThe impact of not having friends and family come in viagra cialis and levitra all 80 off and see us for a year was totally devastating,â she said.
ÂAnd then, the staff all bound up with the masks and the shields on, that too was very difficult to accept.â She summed up the experience in one word. Âscary.â But under alaw Connecticut enacted in June, nursing home residents will be able to designate an âessential support personâ who can help take care of a loved one even during a public health emergency. Connecticut legislators also approved laws this year giving nursing home residents free internet access and digital devices for virtual visits and viagra cialis and levitra all 80 off allowing video cameras in their rooms so family or friends can monitor their care.
Similar benefits are not required by the Centers for Medicare &. Medicaid Services, the federal agency that oversees nursing viagra cialis and levitra all 80 off homes and pays for most of the care they provide. But states can impose additional requirements when federal rules are insufficient or donât exist.
And thatâs exactly what many are doing, spurred by the levitra that hit the frail elderly hardest. During the first 12 months of the levitra, at least 34% of those killed by the levitra viagra cialis and levitra all 80 off were residents of nursing homes and other long-term care facilities, even though they make up fewer than 1% of the American population. The treatment has since reduced levitra-related nursing home deaths to about 1 in 4 erectile dysfunction treatment-related fatalities in the United States, which have risen to more than 624,000, according to The New York Timesâ erectile dysfunction case tracker.
ÂPart of what the levitra did is to expose some of the underlying problems in nursing homes,â said Nina Kohn, a professor at viagra cialis and levitra all 80 off Syracuse University School of Law and a distinguished scholar in elder law at Yale Law School. ÂThis may present an opportunity to correct some of the long-standing problems and reduce some of the key risk factors for neglect and mistreatment.â According to a review of state legislation, 23 geographically and politically diverse states have passed more than 70 levitra-related provisions affecting nursing home operations. States have set minimum staffing levels for nursing homes, expanded visitation, mandated access for residents to virtual communications, required full-time nurses at all times and control specialists, limited ownersâ profits, increased room size, restricted room occupancy to two people and improved emergency response plans.
The statesâ patchwork of protection for nursing home residents viagra cialis and levitra all 80 off is built into the nationâs nursing home care regulatory system, said a CMS spokesperson. ÂCMS sets the minimum requirements that providers need to meet to participate with the Medicare/Medicaid programs,â he said. ÂStates may implement additional requirements to address specific needs in their state â which is a long-standing practice â as long as their requirements go above and beyond, and donât conflict with, federal requirements.â Julie Mayberry, an Arkansas state representative, remembers a nursing home resident in her district who stopped dialysis last summer, she said, and just âgave upâ because he couldnât live âin such an isolated world.â âI donât think anybody would have ever dreamed that we would be telling people that they canât have someone come in to check on them,â said Mayberry, a Republican and the lead sponsor of the âNo Patient Left Alone Act,â an Arkansas law ensuring that residents have an advocate at their bedside.
ÂThis is not someone thatâs viagra cialis and levitra all 80 off just coming in to say hello or bring a get-well card,â she said. When the levitra hit, CMS initially banned visitors to nursing homes but allowed the facilities to permit visits during the lockdown for âcompassionate care,â initially if a family member was dying and later for other emergency situations. Those rules were often misunderstood, Mayberry said viagra cialis and levitra all 80 off.
ÂI was told by a lot of nursing homes that they were really scared to allow any visitor in there because they feared the state of Arkansas coming down on them, and fining them for a violationâ of the federal directive, she said. Jacqueline Collins, a Democrat who represents sections of Chicago in the Illinois State Senate, was also concerned about the effects of social isolation on nursing home residents. ÂThe levitra exacerbated the matter, and served to expose that vulnerability among our long-term care facilities,â said Collins, who proposed legislation to make virtual visits a permanent part of nursing home life by creating viagra cialis and levitra all 80 off a lending library of tablets and other devices residents can borrow.
Gov. J.B. Pritzker is expected to sign the measure.
To reduce the cost of the equipment, the Illinois Department of Public Health will provide grants from funds the state receives when nursing homes settle health and safety violations. Last year, Connecticutâs governor tapped the same fund in his state to buy 800 iPads for nursing home residents. Another issue states are tackling is staffing levels.
An investigation by the New York attorney general found that erectile dysfunction treatment-related death rates from March to August 2020 were lower in nursing homes with higher staffing levels. Studies over the past two decades support the link between the quality of care and staffing levels, said Martha Deaver, president of Arkansas Advocates for Nursing Home Residents. ÂWhen you cut staff, you cut care,â she said.
But under a 1987 federal law, CMS requires facilities only to âhave sufficient nursing staff to attain or maintain the highest practicable ⦠well-being of each resident.â Over the years, states began to tighten up that vague standard by setting their own staffing rules. The levitra accelerated the pace and created âa moment for us to call attention to state legislators and demand change,â said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey. This year states increasingly have established either a minimum number of hours of daily direct care for each resident, or a ratio of nursing staff to residents.
For every eight residents, New Jersey nursing homes must now have at least one certified nursing aide during the day, with other minimums during afternoon and night work shifts. Rhode Islandâs new law requires nursing homes to provide a minimum of 3.58 hours of daily care per resident, and at least one registered nurse must be on duty 24 hours a day every day. Next door in Connecticut, nursing homes must now provide at least three hours of daily direct care per resident next year, one full-time control specialist and one full-time social worker for every 60 residents.
To ensure that facilities are not squeezing excessive profits from the government payment they receive to care for residents, New Jersey lawmakers approved a requirement that nursing homes spend at least 90% of their revenue on direct care. New York facilities must spend 70%, including 40% to pay direct-care workers. In Massachusetts, the governor issued regulations that mandate nursing homes devote at least 75% on direct-care staffing costs and cannot have more than two people living in one room, among other requirements.
Despite the efforts to improve protections for nursing home residents, the hodgepodge of uneven state rules is âa poor substitute for comprehensive federal rules if they were rigorously enforced,â said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group. ÂThe piecemeal approach leads to and exacerbates existing health care disparities,â he said. ÂAnd that puts people â no matter what their wealth, or their race or their gender â at an even greater risk of poor care and inhumane treatment.â Susan Jaffe.
Jaffe.KHN@gmail.com, @SusanJaffe Related Topics Contact Us Submit a Story TipLatest erectile dysfunction News FRIDAY, Aug. 20, 2021 (HealthDay News) Three vaccinated U.S. Senators reported erectile dysfunction s on Thursday, adding to the growing number of breakthrough cases among American politicians.
The positive tests were announced by Sen. Roger Wicker, of Mississippi, Sen. Angus King, of Maine, and Sen.
John Hickenlooper, of Colorado. "Senator Wicker is fully vaccinated against erectile dysfunction treatment, is in good health and is being treated by his Tupelo-based physician," for mild symptoms, according to a statement from his office. "While I am not feeling great, I'm definitely feeling much better than I would have without the treatment," King said in a statement.
"I am taking this diagnosis very seriously, quarantining myself at home and telling the few people I've been in contact with to get tested in order to limit any further spread." On Twitter, Hickenlooper said he had limited symptoms, was grateful to scientists who developed the treatment, and encouraged vaccinated people to get booster shots. The Senate adjourned last Wednesday, so it's unclear whether any of the three men had recent contact with other lawmakers, The New York Times reported. So far, 11 members of the Senate and more than 50 members of the House have tested positive for the erectile dysfunction, according to news items compiled by the political data website Ballotpedia, the Times reported.
Several other vaccinated politicians have recently announced breakthrough cases, including Sen. Lindsey Graham of South Carolina, who said he had tested positive for the levitra after attending a gathering hosted by Sen. Joe Manchin III of West Virginia.
On Tuesday, Gov. Greg Abbott of Texas tested positive and began receiving an antibody treatment. More information Visit the U.S.
Centers for Disease Control and Prevention for more on breakthrough s. SOURCE. The New York Times Robert Preidt and Robin Foster Copyright © 2021 HealthDay.
When the erectile dysfunction hit Martha Lelandâs average cost of levitra Connecticut nursing home last year, she and dozens of other residents contracted the disease while the facility was can you buy levitra without a prescription on lockdown. Twenty-eight residents died, including her roommate. âThe impact of not having friends and family come in and see us for a year can you buy levitra without a prescription was totally devastating,â she said.
ÂAnd then, the staff all bound up with the masks and the shields on, that too was very difficult to accept.â She summed up the experience in one word. Âscary.â But under alaw Connecticut enacted in June, nursing home residents will be able to designate an âessential support personâ who can help take care of a loved one even during a public health emergency. Connecticut legislators also approved laws this year giving nursing home residents free internet access and digital devices for virtual visits and allowing video cameras in can you buy levitra without a prescription their rooms so family or friends can monitor their care.
Similar benefits are not required by the Centers for Medicare &. Medicaid Services, the federal agency that oversees nursing homes can you buy levitra without a prescription and pays for most of the care they provide. But states can impose additional requirements when federal rules are insufficient or donât exist.
And thatâs exactly what many are doing, spurred by the levitra that hit the frail elderly hardest. During the first can you buy levitra without a prescription 12 months of the levitra, at least 34% of those killed by the levitra were residents of nursing homes and other long-term care facilities, even though they make up fewer than 1% of the American population. The treatment has since reduced levitra-related nursing home deaths to about 1 in 4 erectile dysfunction treatment-related fatalities in the United States, which have risen to more than 624,000, according to The New York Timesâ erectile dysfunction case tracker.
ÂPart of what the levitra can you buy levitra without a prescription did is to expose some of the underlying problems in nursing homes,â said Nina Kohn, a professor at Syracuse University School of Law and a distinguished scholar in elder law at Yale Law School. ÂThis may present an opportunity to correct some of the long-standing problems and reduce some of the key risk factors for neglect and mistreatment.â According to a review of state legislation, 23 geographically and politically diverse states have passed more than 70 levitra-related provisions affecting nursing home operations. States have set minimum staffing levels for nursing homes, expanded visitation, mandated access for residents to virtual communications, required full-time nurses at all times and control specialists, limited ownersâ profits, increased room size, restricted room occupancy to two people and improved emergency response plans.
The statesâ patchwork of protection for nursing home residents is built into the nationâs nursing home care regulatory system, said a can you buy levitra without a prescription CMS spokesperson. ÂCMS sets the minimum requirements that providers need to meet to participate with the Medicare/Medicaid programs,â he said. ÂStates may implement additional requirements to address specific needs in their state â which is a long-standing practice â as long as their requirements go above and beyond, and donât conflict with, federal requirements.â Julie Mayberry, an Arkansas state representative, remembers a nursing home resident in her district who stopped dialysis last summer, she said, and just âgave upâ because he couldnât live âin such an isolated world.â âI donât think anybody would have ever dreamed that we would be telling people that they canât have someone come in to check on them,â said Mayberry, a Republican and the lead sponsor of the âNo Patient Left Alone Act,â an Arkansas law ensuring that residents have an advocate at their bedside.
ÂThis is can you buy levitra without a prescription not someone thatâs just coming in to say hello or bring a get-well card,â she said. When the levitra hit, CMS initially banned visitors to nursing homes but allowed the facilities to permit visits during the lockdown for âcompassionate care,â initially if a family member was dying and later for other emergency situations. Those rules were often misunderstood, Mayberry can you buy levitra without a prescription said.
ÂI was told by a lot of nursing homes that they were really scared to allow any visitor in there because they feared the state of Arkansas coming down on them, and fining them for a violationâ of the federal directive, she said. Jacqueline Collins, a Democrat who represents sections of Chicago in the Illinois State Senate, was also concerned about the effects of social isolation on nursing home residents. ÂThe levitra exacerbated the matter, and served to expose that vulnerability among our long-term care facilities,â said Collins, who proposed legislation to make virtual visits a permanent can you buy levitra without a prescription part of nursing home life by creating a lending library of tablets and other devices residents can borrow.
Gov. J.B. Pritzker is expected to sign the measure.
To reduce the cost of the equipment, the Illinois Department of Public Health will provide grants from funds the state receives when nursing homes settle health and safety violations. Last year, Connecticutâs governor tapped the same fund in his state to buy 800 iPads for nursing home residents. Another issue states are tackling is staffing levels.
An investigation by the New York attorney general found that erectile dysfunction treatment-related death rates from March to August 2020 were lower in nursing homes with higher staffing levels. Studies over the past two decades support the link between the quality of care and staffing levels, said Martha Deaver, president of Arkansas Advocates for Nursing Home Residents. ÂWhen you cut staff, you cut care,â she said.
But under a 1987 federal law, CMS requires facilities only to âhave sufficient nursing staff to attain or maintain the highest practicable ⦠well-being of each resident.â Over the years, states began to tighten up that vague standard by setting their own staffing rules. The levitra accelerated the pace and created âa moment for us to call attention to state legislators and demand change,â said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey. This year states increasingly have established either a minimum number of hours of daily direct care for each resident, or a ratio of nursing staff to residents.
For every eight residents, New Jersey nursing homes must now have at least one certified nursing aide during the day, with other minimums during afternoon and night work shifts. Rhode Islandâs new law requires nursing homes to provide a minimum of 3.58 hours of daily care per resident, and at least one registered nurse must be on duty 24 hours a day every day. Next door in Connecticut, nursing homes must now provide at least three hours of daily direct care per resident next year, one full-time control specialist and one full-time social worker for every 60 residents.
To ensure that facilities are not squeezing excessive profits from the government payment they receive to care for residents, New Jersey lawmakers approved a requirement that nursing homes spend at least 90% of their revenue on direct care. New York facilities must spend 70%, including 40% to pay direct-care workers. In Massachusetts, the governor issued regulations that mandate nursing homes devote at least 75% on direct-care staffing costs and cannot have more than two people living in one room, among other requirements.
Despite the efforts to improve protections for nursing home residents, the hodgepodge of uneven state rules is âa poor substitute for comprehensive federal rules if they were rigorously enforced,â said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group. ÂThe piecemeal approach leads to and exacerbates existing health care disparities,â he said. ÂAnd that puts people â no matter what their wealth, or their race or their gender â at an even greater risk of poor care and inhumane treatment.â Susan Jaffe.
Jaffe.KHN@gmail.com, @SusanJaffe Related Topics Contact Us Submit a Story TipLatest erectile dysfunction News FRIDAY, Aug. 20, 2021 (HealthDay News) Three vaccinated U.S. Senators reported erectile dysfunction s on Thursday, adding to the growing number of breakthrough cases among American politicians.
The positive tests were announced by Sen. Roger Wicker, of Mississippi, Sen. Angus King, of Maine, and Sen.
John Hickenlooper, of Colorado. "Senator Wicker is fully vaccinated against erectile dysfunction treatment, is in good health and is being treated by his Tupelo-based physician," for mild symptoms, according to a statement from his office. "While I am not feeling great, I'm definitely feeling much better than I would have without the treatment," King said in a statement.
"I am taking this diagnosis very seriously, quarantining myself at home and telling the few people I've been in contact with to get tested in order to limit any further spread." On Twitter, Hickenlooper said he had limited symptoms, was grateful to scientists who developed the treatment, and encouraged vaccinated people to get booster shots. The Senate adjourned last Wednesday, so it's unclear whether any of the three men had recent contact with other lawmakers, The New York Times reported. So far, 11 members of the Senate and more than 50 members of the House have tested positive for the erectile dysfunction, according to news items compiled by the political data website Ballotpedia, the Times reported.
Several other vaccinated politicians have recently announced breakthrough cases, including Sen. Lindsey Graham of South Carolina, who said he had tested positive for the levitra after attending a gathering hosted by Sen. Joe Manchin III of West Virginia.
On Tuesday, Gov. Greg Abbott of Texas tested positive and began receiving an antibody treatment. More information Visit the U.S.
Centers for Disease Control and Prevention for more on breakthrough s. SOURCE. The New York Times Robert Preidt and Robin Foster Copyright © 2021 HealthDay.
Literally literacyThough this issue wonât appear for another 3-4 weeks, given the painful events unravelling in Afghanistan, it would feel banal to the point of negligence to fail to ask âwhere are we goingâ in terms of global human rights.Many years ago, I took a short course on âprimary health care in low and middle countriesâ to equip levitra 20mg street price myself with some knowledge of the public health issues I was likely to encounter first in Sudan and Can you buy viagra without a prescription later Afghanistan. Though the teaching was a little too âtouchy feelyâ for my taste, it left an impression based on one talk and one message. Female literacy levitra 20mg street price.
Once assimilated, I realised that this was central to everythingI was based close to Kabul, during the immediate, relatively upbeat (if not as openly urbane as the 1970s) post-Soviet withdrawal era and have maintained some contact in the form of research collaborations with colleagues in the Afghan Ministry of Health. In parallel, we have seen the tantalising promise of a future of freedom and childrenâs futures and womenâs rights snatched away so abruptly, the purple period from 2001 to 2021 already feeling illusorySo, when the headlines change as they inevitably will (tabloid attention no doubt turning to the off-duty improprieties of a footballer or mid-ranking cabinet member) donât forget that if classrooms can be kept open, then there is still hope.Global child health. Maternal and perinatal outcomeContinuing the neonatal sepsis theme discussed by Carolin Fleischmann and colleagues in the August issue (https://adc.bmj.com/content/106/8/745) Adama Baguiyaâs WHO maternal sepsis (GLOSS) group takes another angle, levitra 20mg street price the identification of high risk babies by the mothersâ peripartum condition.
Using data from 43 LMICs, neonatal outcomes of mothers with suspected or proven sepsis were compared with those in whom there were no concerns. The direction of effect (predictive) was perhaps not surprising, though the magnitude was. A third of the levitra 20mg street price babies of these women had adverse outcomes.
25% near miss events (outcomes requiring intervention or resuscitation of some sort) and a 10% mortality with an OR of 3.8 (95% CI 2.0 to 7.1) for the most severely unwell mothers. How then can these women be identified earlier before both they and the fetus starts to decompensate? levitra 20mg street price. See page 946Opiates in analgesiaWe all have a preferred opiate for analgesia resistant to first and second line alternatives and this particular choice has been, for as long as I can remember, if not divisive then factionalising.From buprenorphine patches to intranasal fentanyl to oral dextromoramide (the latter admittedly now largely a museum piece) to codeine, each has its (often vocal) proponents, the volume of their arguments not necessarily a correlate of analgesic effect.In the Drugs and Therapeutics section, Sarah Spenard and colleagues address this chestnut in their systematic review of the literature comparing morphine and hydromorphone, the turn to opioid in the face of the nausea and (histamine agonism-related) pruritus for which morphine itself is renowned.
They found high quality evidence from 4 RCTs concluding there was nothing to choose between them in terms of therapeutic or side effects. So, rather than weighing up which opiate, the only question worth asking is âis there a reason not to start one levitra 20mg street price now?. Â in the face of a child struggling on high dose NSAID treatment.
See page 1002Safety reportingWe are the proud discovers of a new antimicrobial drug, letâs call it âviroblast 21â, the performance of which in phase two trials has been (our brochures proclaim) âbreathtakingâ. Agog with excitement, we proceed to the âdefinitiveâ randomised controlled trial in children admitted to PICU for respiratory support levitra 20mg street price. The âfully adjusted analysesâ (inverted commas, of course intentional) repay the faith we had in the drug, a âjaw droppingâ protective HR in time to recovery of 0.2 (95% CI 0.1 to 0.35).
The tension levitra 20mg street price is released and celebrations can begin⦠or can they?. The message in Taco Jan Pilsâ and colleaguesâ systematic review of trials reporting is that, even now, in the era of EQUATOR, CONSORT, siblings and half siblings safety data is often overlooked. Though reporting has improved over the decade since their previous review, itâs baffling that it isnât 100%.
Part of levitra 20mg street price the story is missing. Taking a tangential trajectory, it would be reasonable to argue that the sort of safety reporting leaves a few more loopholes. I want to know whether children can swallow the preparation.
Whether it levitra 20mg street price tastes good (or at least isnât emetogenic). And that the cost is not crippling for the health service or patients and parents by which it will ultimately be financed. This too (the economic burden) is also to my mind levitra 20mg street price a side effect.
Where resources are finite, something else will have to give. Maybe that mouthwatering âeffect sizeâ didnât tell us everything we need to know. See page 1010Fixing a hole where the levitra 20mg street price rain gets inThe reality is that much of what we do, despite the best public health preventative measures is reactive.
The asthmatic childâs parents of âwho only ever smoke outsideâ are advised to stop or get help/gum/patches.Iâm digressing but only slightly as, what Iâm getting at are the upstream (preventative) vs downstream (symptomatic) approaches. Until recently, all treatment in cystic fibrosis was, by necessity, reactive/downstream. The advent of the CF transmembrane modulator family, correctors and potentiators levitra 20mg street price has changed all this.
Iolo Doullâs compelling review from the discovery of the molecule to the consistent improvements in all objective measures of lung and overall health by its augmentation testifies to this. This is exciting levitra 20mg street price for other reasons too. In the same way that anti-retroviral treatment in HIV became bolder and gathered pace, there is impetus for novel orphan drug development with implications beyond CF alone.
See page 941(Pierre-)Robin sequence (RS) is characterised by mandibular retrognathia, glossoptosis and upper airway obstruction (UAO). To alleviate the latter, placing such infants prone was already suggested as a first-line treatment by Robin himself, the levitra 20mg street price eponym of this condition. Indeed, it appears intuitively plausible that gravity will help shifting the mandible forward during sleep.
Against this background, it was not surprising that the prone position was implemented by about two-thirds of respondents to a recent survey focusing on interventions used in infants with RS.1In neonatology, however, we have learnt the hard way that what seems plausible is not always effective and, particularly, safe. Thus, we need to scrutinise the evidence for recommending prone positioning to resolve UAO in levitra 20mg street price infants with RS. Objective data on the effectiveness of this intervention, however, are sparse.
A retrospective analysis of sleep study data in 18 infants with RS (mean age, 1.5 months) found a higher sleep efficiency in the prone position, but no significant reduction in the severity of obstructive sleep apnoea (OSA).2 A longitudinal prospective study in 14 infants with RS (mean age, 1.8 months) reported a median Obstructive ApnoeaâHypopnoea â¦.
Literally literacyThough this can you buy levitra without a prescription issue wonât appear for another 3-4 weeks, given the painful events unravelling in Afghanistan, it would feel banal to the point of negligence to fail to ask âwhere are we goingâ in terms of global human rights.Many years ago, I took a short course on âprimary health care in low and middle countriesâ to equip myself with some knowledge of the public health issues I was likely to encounter first in Sudan and later Afghanistan. Though the teaching was a little too âtouchy feelyâ for my taste, it left an impression based on one talk and one message. Female literacy can you buy levitra without a prescription.
Once assimilated, I realised that this was central to everythingI was based close to Kabul, during the immediate, relatively upbeat (if not as openly urbane as the 1970s) post-Soviet withdrawal era and have maintained some contact in the form of research collaborations with colleagues in the Afghan Ministry of Health. In parallel, we have seen the tantalising promise of a future of freedom and childrenâs futures and womenâs rights snatched away so abruptly, the purple period from 2001 to 2021 already feeling illusorySo, when the headlines change as they inevitably will (tabloid attention no doubt turning to the off-duty improprieties of a footballer or mid-ranking cabinet member) donât forget that if classrooms can be kept open, then there is still hope.Global child health. Maternal and perinatal outcomeContinuing the neonatal sepsis can you buy levitra without a prescription theme discussed by Carolin Fleischmann and colleagues in the August issue (https://adc.bmj.com/content/106/8/745) Adama Baguiyaâs WHO maternal sepsis (GLOSS) group takes another angle, the identification of high risk babies by the mothersâ peripartum condition.
Using data from 43 LMICs, neonatal outcomes of mothers with suspected or proven sepsis were compared with those in whom there were no concerns. The direction of effect (predictive) was perhaps not surprising, though the magnitude was. A third can you buy levitra without a prescription of the babies of these women had adverse outcomes.
25% near miss events (outcomes requiring intervention or resuscitation of some sort) and a 10% mortality with an OR of 3.8 (95% CI 2.0 to 7.1) for the most severely unwell mothers. How then can these women be identified earlier before both they and the fetus starts to can you buy levitra without a prescription decompensate?. See page 946Opiates in analgesiaWe all have a preferred opiate for analgesia resistant to first and second line alternatives and this particular choice has been, for as long as I can remember, if not divisive then factionalising.From buprenorphine patches to intranasal fentanyl to oral dextromoramide (the latter admittedly now largely a museum piece) to codeine, each has its (often vocal) proponents, the volume of their arguments not necessarily a correlate of analgesic effect.In the Drugs and Therapeutics section, Sarah Spenard and colleagues address this chestnut in their systematic review of the literature comparing morphine and hydromorphone, the turn to opioid in the face of the nausea and (histamine agonism-related) pruritus for which morphine itself is renowned.
They found high quality evidence from 4 RCTs concluding there was nothing to choose between them in terms of therapeutic or side effects. So, rather than weighing can you buy levitra without a prescription up which opiate, the only question worth asking is âis there a reason not to start one now?. Â in the face of a child struggling on high dose NSAID treatment.
See page 1002Safety reportingWe are the proud discovers of a new antimicrobial drug, letâs call it âviroblast 21â, the performance of which in phase two trials has been (our brochures proclaim) âbreathtakingâ. Agog with can you buy levitra without a prescription excitement, we proceed to the âdefinitiveâ randomised controlled trial in children admitted to PICU for respiratory support. The âfully adjusted analysesâ (inverted commas, of course intentional) repay the faith we had in the drug, a âjaw droppingâ protective HR in time to recovery of 0.2 (95% CI 0.1 to 0.35).
The tension can you buy levitra without a prescription is released and celebrations can begin⦠or can they?. The message in Taco Jan Pilsâ and colleaguesâ systematic review of trials reporting is that, even now, in the era of EQUATOR, CONSORT, siblings and half siblings safety data is often overlooked. Though reporting has improved over the decade since their previous review, itâs baffling that it isnât 100%.
Part of the can you buy levitra without a prescription story is missing. Taking a tangential trajectory, it would be reasonable to argue that the sort of safety reporting leaves a few more loopholes. I want to know whether children can swallow the preparation.
Whether it tastes good (or at least can you buy levitra without a prescription isnât emetogenic). And that the cost is not crippling for the health service or patients and parents by which it will ultimately be financed. This too (the economic burden) can you buy levitra without a prescription is also to my mind a side effect.
Where resources are finite, something else will have to give. Maybe that mouthwatering âeffect sizeâ didnât tell us everything we need to know. See page can you buy levitra without a prescription 1010Fixing a hole where the rain gets inThe reality is that much of what we do, despite the best public health preventative measures is reactive.
The asthmatic childâs parents of âwho only ever smoke outsideâ are advised to stop or get help/gum/patches.Iâm digressing but only slightly as, what Iâm getting at are the upstream (preventative) vs downstream (symptomatic) approaches. Until recently, all treatment in cystic fibrosis was, by necessity, reactive/downstream. The advent can you buy levitra without a prescription of the CF transmembrane modulator family, correctors and potentiators has changed all this.
Iolo Doullâs compelling review from the discovery of the molecule to the consistent improvements in all objective measures of lung and overall health by its augmentation testifies to this. This is can you buy levitra without a prescription exciting for other reasons too. In the same way that anti-retroviral treatment in HIV became bolder and gathered pace, there is impetus for novel orphan drug development with implications beyond CF alone.
See page 941(Pierre-)Robin sequence (RS) is characterised by mandibular retrognathia, glossoptosis and upper airway obstruction (UAO). To alleviate the latter, placing such infants prone was already suggested as a first-line treatment by Robin himself, the eponym of can you buy levitra without a prescription this condition. Indeed, it appears intuitively plausible that gravity will help shifting the mandible forward during sleep.
Against this background, it was not surprising that the prone position was implemented by about two-thirds of respondents to a recent survey focusing on interventions used in infants with RS.1In neonatology, however, we have learnt the hard way that what seems plausible is not always effective and, particularly, safe. Thus, we need to scrutinise the evidence can you buy levitra without a prescription for recommending prone positioning to resolve UAO in infants with RS. Objective data on the effectiveness of this intervention, however, are sparse.
A retrospective analysis of sleep study data in 18 infants with RS (mean age, 1.5 months) found a higher sleep efficiency in the prone position, but no significant reduction in the severity of obstructive sleep apnoea (OSA).2 A longitudinal prospective study in 14 infants with RS (mean age, 1.8 months) reported a median Obstructive ApnoeaâHypopnoea â¦.
At a glance how to use levitra levitra target pharmacy. Medicare enrollment in Hawaii how to use levitra How many Hawaiians are enrolled in Medicare?. As of July 2020, 280,006 Hawaii residents â nearly 20 percent of the stateâs population â were enrolled in Medicare.For most Americans, filing for Medicare is part of turning 65.
But Medicare coverage is also available to people under the age of 65 who have been how to use levitra receiving disability benefits for at least two years, or who have ALS or end-stage renal disease. Nationwide, 85 percent of Medicare beneficiaries are eligible due to being at least 65 years old, while the other 15 percent are under 65.Hawaii has the smallest percentage of disabled Medicare beneficiaries of any state in the country â just 9 percent Hawaiiâs Medicare beneficiaries are under 65 and eligible due to a disability (if we also include US territories, just 8 percent of the Virgin Islandsâ Medicare beneficiaries are under 65). The other 91 percent of Hawaiiâs Medicare beneficiaries are how to use levitra eligible due to their age.Medicare Advantage in HawaiiIn Hawaii in 2018, 45 percent of Medicare beneficiaries were enrolled in private Medicare Advantage plans â as opposed to 34 percent of Medicare beneficiaries nationwide.
The remaining 55 percent of the stateâs beneficiaries had Medicare coverage enrollment under Original Medicare.Hawaii has five counties, and the availability of Medicare Advantage plans varies by county. In Honolulu County in 2020, Medicare how to use levitra beneficiaries can select from among 20 different Medicare Advantage plans. But in tiny Kalawao County (which had just 86 residents as of 2019), there are only six Medicare Advantage plans available (itâs noteworthy that in some low-population areas in other states â including the entire state of Alaska â there are no Medicare Advantage plans available at all, but plans are available throughout Hawaii).Medicare Advantage enrollment is available when a person is first eligible for Medicare, and thereâs also an annual enrollment period in the fall when beneficiaries can enroll in Medicare Advantage plans if they choose to do so.
And there is another window â the Medicare Advantage open enrollment period (January 1 to March 31) â during which people who are already enrolled in Medicare Advantage can switch their Medicare Advantage enrollment to a different plan or drop their Medicare Advantage plan and enroll in Original Medicare how to use levitra instead.Medigap in HawaiiMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.As of 2020, there are 13 insurers offering Medigap plans in Hawaii.Medigap plans are standardized under federal rules, although states can add their own regulations. Hawaiiâs Medigap regulations are available here.The state also requires (see §16-12-6.2) all Medigap insurers to offer all plans on a guaranteed-issue basis (and without adjusting premiums based on medical underwriting) to any enrollee during the six-month window that begins when the person is enrolled in Medicare Part B. This applies regardless of age in Hawaii how to use levitra.
Federal law how to use levitra grants a six-month guaranteed-issue open enrollment window, but only when people are enrolled in Part B and also age 65. So Hawaiiâs law extends the same protections to people who are under 65 and eligible for Medicare as a result of a disability. As noted above, Medicare in Hawaii has the nationâs lowest percentage of beneficiaries who are eligible due to a disability.The majority of the states have adopted rules to ensure at least some access to Medigap plans for enrollees under the age of 65, but unlike most of them Hawaii how to use levitra also prohibits Medigap insurers from charging higher premiums for people under the age of 65, based on their disability.
So while itâs common to see under-65 Medigap policies sold in other states with premiums that are well above the age-65 premiums, thatâs not the case in Hawaii.Hawaii Medicare Part DOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan that includes integrated Medicare Part D coverage, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D prescription drug plan.For how to use levitra 2020 coverage, insurers are offering 25 stand-alone Medicare Part D plans in Hawaii, with premiums ranging from $13 to $87 per month.As of mid-2020, there were 72,585 people with Medicare in Hawaii who had prescription coverage under stand-alone Medicare Part D plans. Another 128,545 beneficiaries had Medicare Part D coverage integrated with their Medicare Advantage plans, so the majority of Part D coverage in Hawaii is provided via Medicare Advantage plans as opposed to stand-alone Medicare Part D plans (most Medicare Advantage plans include Part D coverage.
Stand-alone Medicare Part D plans are usually used to supplement how to use levitra Original Medicare, since it never includes prescription coverage).Medicare Part D enrollment is an option when a person first submits their Medicare application in Hawaii, or when they lose access to other creditable drug coverage (eg, they retire and lose the drug coverage that they had from their employer). The annual open enrollment period that runs from October 15 to December 7 each year is also an opportunity for Medicare beneficiaries to sign up for a Part D plan or switch to a different Part D plan. Medicare spending in HawaiiAs of 2018, per-beneficiary spending on Medicare in Hawaii was the how to use levitra lowest in the nation, at $6,971.
Nationwide, the average was $10,096 (and on the high end, per-beneficiary spending exceeded $11,000 in Florida, Texas, Mississippi, Oklahoma, and Louisiana). Thatâs according to data that were standardized to account for regional how to use levitra differences in payment rates, but the data did not include costs under Medicare Advantage, and Hawaii has a larger-than-average share of its Medicare population enrolled in Medicare Advantage plans.Medicare in Hawaii. Resources for Medicare beneficiaries and caregiversQuestions about Medicare eligibility in Hawaii or Medicare enrollment in how to use levitra Hawaii?.
You can contact the Hawaii State Health Insurance Assistance Program with questions related to Medicare in Hawaii.The state of Hawaiiâs Employer-Union Health Benefits Trust Fund also has an overview of Medicare.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written how to use levitra dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Medicare in Maryland at a glance Medicare enrollment in Maryland The number of Maryland residents with Medicare coverage surpassed one million as of April 2018.
By July 2020, it stood at 1,054,500 â about 17 percent of the stateâs population enrolled in Medicare.87 percent of Marylandâs Medicare beneficiaries are eligible based on their age (ie, they are at least 65 years old), while the other 13 percent are eligible due to a disability that has lasted at least 24 months (people with ALS or end-stage renal disease do not have to wait how to use levitra 24 months for their Medicare coverage to take effect). Nationwide, 85 percent of people filing for Medicare benefits are at least 65 years old, while 15 percent are under 65 and eligible due to disability.Medicare Advantage in MarylandNationwide, about a third of all Medicare beneficiaries were enrolled in private Medicare Advantage plans as of 2018. But in Maryland, just 11 percent of Medicare beneficiaries selected Medicare Advantage how to use levitra plans.
Most of the rest were covered under Original Medicare, but there are also some Maryland Medicare beneficiaries with Medicare Cost plan coverage.By mid-2020, about 13 percent of people with Medicare in Maryland were enrolled in private plans (mostly Medicare Advantage plans, but also some Medicare Cost plans), while the other 87 percent were enrolled in Original Medicare. At that point, how to use levitra total private plan enrollment among Medicare beneficiaries nationwide had grown to 40 percent, but Medicare Advantage enrollment continues to be less popular in Maryland.The availability of Medicare Advantage plans in Maryland varies from one county to another. In St.
Maryâs County, Maryland, there is just one how to use levitra Medicare Advantage plan available in 2020. But in Baltimore County and Montgomery County, there are 24 plans and 20 plans available, respectively.Medicare beneficiaries can switch back and forth from Medicare Advantage to Original Medicare or vice versa each fall during the annual open enrollment period (October 15 through December how to use levitra 7). There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MarylandMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules, with ten different plan options available.
In Maryland in 2020, 50 insurers offer Medigap plans, although some only offer a few of the ten plan designs.Under federal rules, Medicare beneficiaries have a six-month window, when they how to use levitra turn 65 and file for benefits under Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if youâre under 65 and eligible for Medicare as a result of a disability.But Maryland is among the majority of the states that ensure at least some access to Medigap plans for enrollees under the age of 65. In Maryland, Medigap insurers are required to offer Plan A to enrollees who are under 65, on a guaranteed-issue basis if the person applies for the Medigap plan within six months of enrolling in Medicare Part B (insurers are also required to offer Medigap Plan D to how to use levitra beneficiaries, but only if the insurer offers that plan to other enrollees.
Insurers that offer Medigap Plan C must also offer it to disabled Medigap enrollees who were already eligible for Medicare prior to 2020. Under federal rules, Medigap plans C and F cannot be sold to anyone who is newly eligible for Medicare how to use levitra in 2020 or later). The requirement that Medigap insurers offer coverage to disabled beneficiaries is a result of Maryland S.B.48, which took effect in 2017.The premiums are higher for enrollees under age 65, although they are given another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point, or pick a plan other than Plan A or C/D.
And Maryland how to use levitra does limit the pricing on Medigap Plan A for disabled enrollees. It cannot exceed the average of the premiums paid for that Plan A by enrollees who are 65 and older.Medicare Part D plans in MarylandOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via Medicaid (if theyâre qualified by low income and assets), a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Part D prescription plan.For 2020 coverage, insurers are offering 27 stand-alone Part D plans available in Maryland, with premiums ranging from $14 to $97 per month.549,075 Maryland Medicare beneficiaries â about 52 percent of the stateâs how to use levitra Medicare population â were enrolled in stand-alone Part D prescription drug plans in Maryland as of July 2020.
Nationwide, about 40 percent of all Medicare beneficiaries were enrolled in stand-alone Part D plans.Most Medicare Advantage plans include Part D prescription drug coverage, so stand-alone Part D plans are typically used to supplement Original Medicare. Enrollment in Original Medicare in Maryland is higher than average, which is why stand-alone Medicare Part D enrollment in Maryland is also higher than average how to use levitra. In addition to the people with stand-alone Part D coverage, nearly 114,000 Medicare beneficiaries in Maryland have Part D coverage as how to use levitra part of their Medicare Advantage coverage.
Medicare spending in MarylandIn 2018, Original Medicare spent an average of $10,115 per beneficiary in Maryland, according to data that were standardized to eliminate regional differences in payment rates. The analysis was only based on Original Medicare spending, so it did not include costs for Medicare Advantage enrollees â but Maryland has a much lower-than-average proportion of its how to use levitra Medicare beneficiaries enrolled in Medicare Advantage.The national average Medicare spending that year was $10,096 per enrollee, so Medicare spending in Maryland was virtually the same as the national average. On the extreme ends of the spectrum, Louisiana had the highest average per-enrollee costs, at $11,932, while Hawaii had the lowest, at $6,971.Medicare in Maryland.
Resources for Medicare beneficiaries and their caregiversIf you need help with your Medicare application in Maryland or have general questions about Medicare eligibility in Maryland, how to use levitra you can contact the Maryland Senior Health Insurance Program.The Maryland Insurance Administration has a comprehensive overview of Medigap in Maryland, and a detailed comparison of how Medigap premiums vary by age and insurer in Maryland.The Maryland Health Care Commissionâs Consumer Guide to Long Term Care is also a good resource for people with Medicare who want to understand how theyâll need to prepare for the potential cost of long-term care.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state how to use levitra health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.At a glance.
Medicare enrollment in Hawaii How many Hawaiians are enrolled in Medicare?. As of July 2020, 280,006 Hawaii residents â nearly 20 percent of the stateâs population â were enrolled in Medicare.For most Americans, filing for Medicare is how to use levitra part of turning 65. But Medicare coverage is also available to people under the age of 65 who have been receiving disability benefits for at least two years, or who have ALS or end-stage renal disease.
Nationwide, 85 percent of Medicare beneficiaries are eligible due to being at least 65 years old, while the other how to use levitra 15 percent are under 65.Hawaii has the smallest percentage of disabled Medicare beneficiaries of any state in the country â just 9 percent Hawaiiâs Medicare beneficiaries are under 65 and eligible due to a disability (if we also include US territories, just 8 percent of the Virgin Islandsâ Medicare beneficiaries are under 65). The other 91 percent of Hawaiiâs Medicare beneficiaries are eligible due to their age.Medicare Advantage in HawaiiIn Hawaii in 2018, 45 percent of Medicare beneficiaries were enrolled in private Medicare Advantage how to use levitra plans â as opposed to 34 percent of Medicare beneficiaries nationwide. The remaining 55 percent of the stateâs beneficiaries had Medicare coverage enrollment under Original Medicare.Hawaii has five counties, and the availability of Medicare Advantage plans varies by county.
In Honolulu County in 2020, Medicare beneficiaries can select from among 20 how to use levitra different Medicare Advantage plans. But in tiny Kalawao County (which had just 86 residents as of 2019), there are only six Medicare Advantage plans available (itâs noteworthy that in some low-population areas in other states â including the entire state of Alaska â there are no Medicare Advantage plans available at all, but plans are available throughout Hawaii).Medicare Advantage enrollment is available when a person is first eligible for Medicare, and thereâs also an annual enrollment period in the fall when beneficiaries can enroll in Medicare Advantage plans if they choose to do so. And there is another window â the Medicare Advantage open enrollment period (January 1 to March 31) â during which people who are already enrolled in Medicare Advantage can switch their Medicare Advantage enrollment to a how to use levitra different plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in HawaiiMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.As of 2020, there are 13 insurers offering Medigap plans in Hawaii.Medigap plans are standardized under federal rules, although states can add their own regulations.
Hawaiiâs Medigap regulations are available here.The state also requires (see §16-12-6.2) all Medigap insurers to offer all plans on a guaranteed-issue basis (and without adjusting premiums based on medical underwriting) to any enrollee during the six-month window that begins when the person is enrolled in Medicare Part B. This applies regardless of age how to use levitra in Hawaii. Federal law grants a six-month guaranteed-issue open enrollment window, but only when people are enrolled in Part B and also age 65.
So Hawaiiâs law extends the same protections to people who are under 65 and eligible for Medicare as a result how to use levitra of a disability. As noted above, Medicare in Hawaii has the nationâs lowest percentage of beneficiaries who are eligible due to a disability.The majority of the states have adopted rules to ensure at least some access to Medigap plans for enrollees under the age of 65, but unlike most of them Hawaii also prohibits Medigap insurers from charging higher premiums for people under the age of 65, based on their disability. So while itâs common to see under-65 Medigap policies sold in other states with premiums that are well above the age-65 premiums, thatâs not the case in Hawaii.Hawaii Medicare Part DOriginal Medicare how to use levitra does not cover outpatient prescription drugs.
But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan that includes integrated Medicare Part D coverage, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D prescription drug plan.For 2020 coverage, insurers are offering 25 stand-alone Medicare Part D plans in Hawaii, with premiums ranging from $13 to $87 per month.As of mid-2020, there were 72,585 people with Medicare in Hawaii who had prescription coverage under stand-alone Medicare Part D plans. Another 128,545 beneficiaries had Medicare Part D coverage integrated with their Medicare Advantage plans, so the majority of Part D coverage in Hawaii is provided via Medicare Advantage plans as opposed to stand-alone Medicare how to use levitra Part D plans (most Medicare Advantage plans include Part D coverage. Stand-alone Medicare Part D plans are usually used to supplement Original Medicare, since it never includes prescription coverage).Medicare Part D enrollment is an option how to use levitra when a person first submits their Medicare application in Hawaii, or when they lose access to other creditable drug coverage (eg, they retire and lose the drug coverage that they had from their employer).
The annual open enrollment period that runs from October 15 to December 7 each year is also an opportunity for Medicare beneficiaries to sign up for a Part D plan or switch to a different Part D plan. Medicare spending in HawaiiAs of 2018, per-beneficiary spending on Medicare in Hawaii was the lowest in how to use levitra the nation, at $6,971. Nationwide, the average was $10,096 (and on the high end, per-beneficiary spending exceeded $11,000 in Florida, Texas, Mississippi, Oklahoma, and Louisiana).
Thatâs according to data that were standardized to account for regional differences in payment rates, how to use levitra but the data did not include costs under Medicare Advantage, and Hawaii has a larger-than-average share of its Medicare population enrolled in Medicare Advantage plans.Medicare in Hawaii. Resources for Medicare beneficiaries and caregiversQuestions about Medicare eligibility in Hawaii or Medicare enrollment in Hawaii?. You can contact the Hawaii State Health Insurance Assistance Program with questions related to Medicare in Hawaii.The state of Hawaiiâs Employer-Union Health Benefits Trust Fund also has an overview of Medicare.Louise Norris is an individual health insurance broker who has been writing about health insurance and how to use levitra health reform since 2006.
She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Medicare in Maryland at a glance Medicare enrollment in Maryland The number of Maryland residents with how to use levitra Medicare coverage surpassed one million as of April 2018. By July 2020, it stood at 1,054,500 â about 17 percent of the stateâs population enrolled in Medicare.87 percent of Marylandâs Medicare beneficiaries are eligible based on their age (ie, they are at least 65 years old), while the other 13 percent are eligible due to a disability that has lasted at least 24 months (people with ALS or end-stage renal disease do not have to wait 24 months for their Medicare coverage to take effect).
Nationwide, 85 percent of people filing for how to use levitra Medicare benefits are at least 65 years old, while 15 percent are under 65 and eligible due to disability.Medicare Advantage in MarylandNationwide, about a third of all Medicare beneficiaries were enrolled in private Medicare Advantage plans as of 2018. But in Maryland, just 11 percent of Medicare beneficiaries selected how to use levitra Medicare Advantage plans. Most of the rest were covered under Original Medicare, but there are also some Maryland Medicare beneficiaries with Medicare Cost plan coverage.By mid-2020, about 13 percent of people with Medicare in Maryland were enrolled in private plans (mostly Medicare Advantage plans, but also some Medicare Cost plans), while the other 87 percent were enrolled in Original Medicare.
At that point, total private plan enrollment among Medicare beneficiaries nationwide had grown to 40 percent, but Medicare Advantage enrollment continues to how to use levitra be less popular in Maryland.The availability of Medicare Advantage plans in Maryland varies from one county to another. In St. Maryâs County, Maryland, there is just how to use levitra one Medicare Advantage plan available in 2020.
But in Baltimore County and Montgomery County, there are 24 plans and 20 plans available, respectively.Medicare beneficiaries can switch back and forth from Medicare Advantage to Original Medicare or vice versa each fall during the annual open enrollment period (October 15 through December 7). There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MarylandMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare how to use levitra on its own.Medigap plans are standardized under federal rules, with ten different plan options available. In Maryland in 2020, 50 insurers offer Medigap plans, although some only offer a few of the ten plan designs.Under federal rules, Medicare beneficiaries have a six-month window, when they turn 65 and file for benefits under Original Medicare, during which coverage is guaranteed issue for Medigap plans.
Federal rules do not, however, guarantee access to a Medigap plan if youâre under 65 and eligible for Medicare as a result of a disability.But Maryland is among how to use levitra the majority of the states that ensure at least some access to Medigap plans for enrollees under the age of 65. In Maryland, Medigap insurers are required to offer Plan A to enrollees who are under 65, on a guaranteed-issue basis if the person applies for the Medigap plan within six months of enrolling in Medicare Part B (insurers are also required to offer Medigap Plan D to beneficiaries, but only if the insurer offers that plan to other enrollees. Insurers that offer Medigap Plan C must also offer it to disabled Medigap enrollees who were already eligible for how to use levitra Medicare prior to 2020.
Under federal rules, Medigap plans C and F cannot be sold to anyone who is how to use levitra newly eligible for Medicare in 2020 or later). The requirement that Medigap insurers offer coverage to disabled beneficiaries is a result of Maryland S.B.48, which took effect in 2017.The premiums are higher for enrollees under age 65, although they are given another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point, or pick a plan other than Plan A or C/D. And Maryland does limit the pricing on Medigap how to use levitra Plan A for disabled enrollees.
It cannot exceed the average of the premiums paid for that Plan A by enrollees who are 65 and older.Medicare Part D plans in MarylandOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via Medicaid (if theyâre qualified by how to use levitra low income and assets), a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Part D prescription plan.For 2020 coverage, insurers are offering 27 stand-alone Part D plans available in Maryland, with premiums ranging from $14 to $97 per month.549,075 Maryland Medicare beneficiaries â about 52 percent of the stateâs Medicare population â were enrolled in stand-alone Part D prescription drug plans in Maryland as of July 2020. Nationwide, about 40 percent of all Medicare beneficiaries were enrolled in stand-alone Part D plans.Most Medicare Advantage plans include Part D prescription drug coverage, so stand-alone Part D plans are typically used to supplement Original Medicare.
Enrollment in Original Medicare in Maryland is higher than average, which is why stand-alone Medicare Part D how to use levitra enrollment in Maryland is also higher than average. In addition to the people with stand-alone Part D coverage, nearly 114,000 Medicare beneficiaries in Maryland have Part D coverage as part of their Medicare Advantage coverage. Medicare spending in MarylandIn 2018, Original Medicare spent an average how to use levitra of $10,115 per beneficiary in Maryland, according to data that were standardized to eliminate regional differences in payment rates.
The analysis was only based on Original Medicare spending, so it did not include costs for Medicare Advantage enrollees â but Maryland has a much lower-than-average proportion of its Medicare beneficiaries enrolled in Medicare Advantage.The national average Medicare spending that year was $10,096 per enrollee, so Medicare spending in Maryland was virtually the same as the national average. On the extreme ends of the spectrum, Louisiana had the highest average per-enrollee costs, at $11,932, how to use levitra while Hawaii had the lowest, at $6,971.Medicare in Maryland. Resources for Medicare beneficiaries and their caregiversIf you need help with your Medicare application in Maryland or have general questions about Medicare eligibility in Maryland, you can contact the Maryland Senior Health Insurance Program.The Maryland Insurance Administration has a comprehensive overview of Medigap in Maryland, and a detailed comparison of how Medigap premiums vary by age and insurer in Maryland.The Maryland Health Care Commissionâs Consumer Guide how to use levitra to Long Term Care is also a good resource for people with Medicare who want to understand how theyâll need to prepare for the potential cost of long-term care.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.
She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly how to use levitra cited by media who cover health reform and by other health insurance experts.REDWOOD CITY, Calif., Sept. 01, 2020 (GLOBE NEWSWIRE) -- Guardant Health, Inc.
(Nasdaq. GH) today announced the company will be participating in the upcoming Morgan Stanley Virtual Healthcare Conference.Guardant Healthâs management is scheduled for a fireside chat on Tuesday, September 15 at 8:45 a.m. Pacific Time / 11:45 a.m.
Eastern Time. Interested parties may access a live and archived webcast of the presentation on the âInvestorsâ section of the company website at. Www.guardanthealth.com.About Guardant HealthGuardant Health is a leading precision oncology company focused on helping conquer cancer globally through use of its proprietary blood tests, vast data sets, and advanced analytics.
The Guardant Health Oncology Platform leverages capabilities to drive commercial adoption, improve patient clinical outcomes and lower healthcare costs across all stages of the cancer care continuum. Guardant Health has launched liquid biopsy-based Guardant360® and GuardantOMNI® tests for advanced stage cancer patients. These tests fuel development of its LUNAR program, which aims to address the needs of early stage cancer patients with neoadjuvant and adjuvant treatment selection, cancer survivors with surveillance, asymptomatic individuals eligible for cancer screening and individuals at a higher risk for developing cancer with early detection.Investor Contact:Carrie Mendivilinvestors@guardanthealth.comMedia Contact:Anna Czenepress@guardanthealth.comCourtney Carrollcourtney.carroll@uncappedcommunications.com Source.
Guardant Health, Inc.erectile dysfunction treatment diagnostic expands testing supply, protects the continuity of essential cancer work at Guardant Health, and helps with reopening at Delaware State UniversityREDWOOD CITY, Calif., Aug. 24, 2020 (GLOBE NEWSWIRE) -- Guardant Health, Inc. (Nasdaq.
GH) announces that the U.S. Food and Drug Administration (FDA) has granted the Guardant-19 test emergency use authorization (EUA) for use in the detection of the novel erectile dysfunction, erectile dysfunction. The test is being offered to Guardant Health employees and select partner organizations through the companyâs CLIA-certified clinical laboratory.The Guardant-19 test is a reverse transcriptase polymerase chain reaction next generation sequencing (rt-PCR-seq) test that detects erectile dysfunction erectile dysfunction nucleic acid from upper respiratory nasal specimens including nasopharyngeal swabs, oropharyngeal swabs, nasal swabs, interior nasal swabs, mid-turbinate nasal swabs, nasopharyngeal wash/aspirates, nasal aspirates, and nasal washes.
The test has a validated limit of detection (LoD) of 125 copies per mL and results are typically returned the next day. The heavily multiplexed testing workflow used has the ability to scale to over 10,000 tests per day.âWhile serving cancer patients remains our top priority, we are proud to be able to leverage our expertise in liquid biopsy testing to contribute to battling the erectile dysfunction treatment levitra by offering a highly accurate test that is truly additive to the testing options available today,â said AmirAli Talasaz, Guardant Health president. ÂSince the beginning of the levitra we believed it was our social responsibility to not only protect the health and safety of our employees, but to also help our greater community with return to work and school initiatives.
It gives me great pride knowing that Guardant Health is able to deliver.âThe Guardant-19 test is being used to help Delaware State University, a Historically Black College &. University, in its efforts to reopen safely. ÂGuardant is providing us with an innovative testing technology to help protect the safety of our entire campus community,â said Tony Allen, president of Delaware State University, which is being advised by nonprofit Testing for America on its reopening plans.âOur mission is to permanently and safely reopen schools, business and the US economy by providing affordable, accessible and frequent testing and screening.
We believe that a testing option like the one provided by Guardant Health can help achieve the highly accurate and rapid results at a scale that we need,â said Dr. Joan Coker, surgeon and Advisory Council member of Testing for America.The Healing Grove Health Center in San Jose, California is another partner organization. ÂWe are thankful for a high-throughput, fast, accurate erectile dysfunction treatment test from Guardant Health,â said Brett Bymaster, the centerâs executive director.
ÂOur patients are low-income and high risk, and we are seeing a high positivity rate. When we catch these positive cases early, we are possibly saving hundreds of people from getting infected with erectile dysfunction treatment by ensuring that they quarantine. By working closely with Guardant Health, we have gotten results quickly and have been able to keep our erectile dysfunction treatment-positive patients recovering at home, limiting the severity of the outbreak in this important community.âTo learn more about accessing the Guardant-19 test, email.
Guardant19support@guardanthealth.com.About Guardant HealthGuardant Health is a leading precision oncology company focused on helping conquer cancer globally through use of its proprietary blood tests, vast data sets, and advanced analytics. The Guardant Health Oncology Platform leverages capabilities to drive commercial adoption, improve patient clinical outcomes and lower healthcare costs across all stages of the cancer care continuum. Guardant Health has launched liquid biopsy-based Guardant360® and GuardantOMNI® tests for advanced stage cancer patients.
These tests fuel development of its LUNAR program, which aims to address the needs of early stage cancer patients with neoadjuvant and adjuvant treatment selection, cancer survivors with surveillance, asymptomatic individuals eligible for cancer screening and individuals at a higher risk for developing cancer with early detection.Investor Contact:Carrie Mendivilinvestors@guardanthealth.comMedia Contact:Anna Czenepress@guardanthealth.comCourtney Carrollcourtney.carroll@uncappedcommunications.com Source. Guardant Health, Inc..
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Medicare spending in HawaiiAs of 2018, per-beneficiary spending can you buy levitra without a prescription on Medicare in Hawaii was the lowest in the nation, at $6,971. Nationwide, the average was $10,096 (and on the high end, per-beneficiary spending exceeded $11,000 in Florida, Texas, Mississippi, Oklahoma, and Louisiana). Thatâs according to data that were standardized to account for regional differences in payment rates, but the data did not include costs under Medicare Advantage, and Hawaii has a larger-than-average share of its Medicare population enrolled in can you buy levitra without a prescription Medicare Advantage plans.Medicare in Hawaii. Resources for Medicare beneficiaries and caregiversQuestions about Medicare eligibility in Hawaii or Medicare can you buy levitra without a prescription enrollment in Hawaii?.
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Nationwide, 85 percent of people filing for Medicare benefits are at least 65 years old, while 15 percent are under 65 and eligible due to disability.Medicare Advantage in MarylandNationwide, about a third of all Medicare beneficiaries were enrolled in private Medicare Advantage plans as of 2018. But in Maryland, just 11 percent of Medicare beneficiaries selected Medicare Advantage can you buy levitra without a prescription plans. Most of the rest were covered under Original Medicare, but there are also some Maryland Medicare beneficiaries with Medicare Cost plan coverage.By mid-2020, about 13 percent of people with Medicare in Maryland were enrolled in private plans (mostly Medicare Advantage plans, but also some Medicare Cost plans), while the other 87 percent were enrolled in Original Medicare. At that point, total private plan enrollment among Medicare beneficiaries nationwide had grown to 40 percent, but Medicare Advantage enrollment continues to be less can you buy levitra without a prescription popular in Maryland.The availability of Medicare Advantage plans in Maryland varies from one county to another.
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Under federal rules, can you buy levitra without a prescription Medigap plans C and F cannot be sold to anyone who is newly eligible for Medicare in 2020 or later). The requirement that Medigap insurers offer coverage to disabled beneficiaries is a result of Maryland S.B.48, which took effect in 2017.The premiums are higher for enrollees under age 65, although they are given another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point, or pick a plan other than Plan A or C/D. And Maryland does limit the can you buy levitra without a prescription pricing on Medigap Plan A for disabled enrollees. It cannot exceed the average of the premiums paid for that Plan A by enrollees who are 65 and older.Medicare Part D plans in MarylandOriginal Medicare does not cover outpatient prescription drugs.
But Medicare beneficiaries can get prescription coverage via Medicaid (if theyâre qualified by low income and assets), a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Part D prescription plan.For 2020 coverage, insurers are offering 27 stand-alone Part D plans can you buy levitra without a prescription available in Maryland, with premiums ranging from $14 to $97 per month.549,075 Maryland Medicare beneficiaries â about 52 percent of the stateâs Medicare population â were enrolled in stand-alone Part D prescription drug plans in Maryland as of July 2020. Nationwide, about 40 percent of all Medicare beneficiaries were enrolled in stand-alone Part D plans.Most Medicare Advantage plans include Part D prescription drug coverage, so stand-alone Part D plans are typically used to supplement Original Medicare. Enrollment in Original Medicare in Maryland is higher than can you buy levitra without a prescription average, which is why stand-alone Medicare Part D enrollment in Maryland is also higher than average. In addition to the people with stand-alone Part D coverage, nearly 114,000 Medicare beneficiaries in Maryland have Part D coverage can you buy levitra without a prescription as part of their Medicare Advantage coverage.
Medicare spending in MarylandIn 2018, Original Medicare spent an average of $10,115 per beneficiary in Maryland, according to data that were standardized to eliminate regional differences in payment rates. The analysis was only based on Original Medicare spending, can you buy levitra without a prescription so it did not include costs for Medicare Advantage enrollees â but Maryland has a much lower-than-average proportion of its Medicare beneficiaries enrolled in Medicare Advantage.The national average Medicare spending that year was $10,096 per enrollee, so Medicare spending in Maryland was virtually the same as the national average. On the extreme ends of the spectrum, Louisiana had the highest average per-enrollee costs, at $11,932, while Hawaii had the lowest, at $6,971.Medicare in Maryland. Resources for Medicare beneficiaries and their caregiversIf you need help with your Medicare application in Maryland or have general questions about Medicare eligibility in Maryland, you can contact the Maryland Senior Health Insurance Program.The Maryland Insurance Administration has a comprehensive overview of Medigap in Maryland, and a detailed comparison of how Medigap premiums vary can you buy levitra without a prescription by age and insurer in Maryland.The Maryland Health Care Commissionâs Consumer Guide to Long Term Care is also a good resource for people with Medicare who want to understand how theyâll need to prepare for the potential cost of long-term care.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.
She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited can you buy levitra without a prescription by media who cover health reform and by other health insurance experts.At a glance. Medicare enrollment in Hawaii How many Hawaiians are enrolled in Medicare?. As of July 2020, 280,006 Hawaii residents â nearly 20 percent of the stateâs population â were enrolled in Medicare.For most Americans, can you buy levitra without a prescription filing for Medicare is part of turning 65.
But Medicare coverage is also available to people under the age of 65 who have been receiving disability benefits for at least two years, or who have ALS or end-stage renal disease. Nationwide, 85 percent of Medicare beneficiaries are eligible due to being at least 65 years old, while the other 15 percent are under 65.Hawaii has the smallest percentage of disabled Medicare beneficiaries of any state in the country â just 9 percent Hawaiiâs Medicare beneficiaries are under 65 and eligible due to a disability (if we also include US territories, just 8 percent can you buy levitra without a prescription of the Virgin Islandsâ Medicare beneficiaries are under 65). The other 91 percent of Hawaiiâs Medicare beneficiaries are eligible due to their age.Medicare Advantage in HawaiiIn Hawaii in 2018, 45 percent of Medicare beneficiaries were can you buy levitra without a prescription enrolled in private Medicare Advantage plans â as opposed to 34 percent of Medicare beneficiaries nationwide. The remaining 55 percent of the stateâs beneficiaries had Medicare coverage enrollment under Original Medicare.Hawaii has five counties, and the availability of Medicare Advantage plans varies by county.
In Honolulu County in 2020, Medicare beneficiaries can select can you buy levitra without a prescription from among 20 different Medicare Advantage plans. But in tiny Kalawao County (which had just 86 residents as of 2019), there are only six Medicare Advantage plans available (itâs noteworthy that in some low-population areas in other states â including the entire state of Alaska â there are no Medicare Advantage plans available at all, but plans are available throughout Hawaii).Medicare Advantage enrollment is available when a person is first eligible for Medicare, and thereâs also an annual enrollment period in the fall when beneficiaries can enroll in Medicare Advantage plans if they choose to do so. And there is another window â the Medicare Advantage open enrollment period (January 1 to March 31) â during which people who are already enrolled in Medicare Advantage can switch their Medicare Advantage enrollment to a different plan can you buy levitra without a prescription or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in HawaiiMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.As of 2020, there are 13 insurers offering Medigap plans in Hawaii.Medigap plans are standardized under federal rules, although states can add their own regulations. Hawaiiâs Medigap regulations are available here.The state also requires (see §16-12-6.2) all Medigap insurers to offer all plans on a guaranteed-issue basis (and without adjusting premiums based on medical underwriting) to any enrollee during the six-month window that begins when the person is enrolled in Medicare Part B.
This applies regardless of age in can you buy levitra without a prescription Hawaii. Federal law grants a six-month guaranteed-issue open enrollment window, but only when people are enrolled in Part B and also age 65. So Hawaiiâs can you buy levitra without a prescription law extends the same protections to people who are under 65 and eligible for Medicare as a result of a disability. As noted above, Medicare in Hawaii has the nationâs lowest percentage of beneficiaries who are eligible due to a disability.The majority of the states have adopted rules to ensure at least some access to Medigap plans for enrollees under the age of 65, but unlike most of them Hawaii also prohibits Medigap insurers from charging higher premiums for people under the age of 65, based on their disability.
So while itâs common to see under-65 Medigap policies sold in can you buy levitra without a prescription other states with premiums that are well above the age-65 premiums, thatâs not the case in Hawaii.Hawaii Medicare Part DOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via a Medicare Advantage plan that includes integrated Medicare Part D coverage, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Medicare Part D prescription drug plan.For 2020 coverage, insurers are offering 25 stand-alone Medicare Part D plans in Hawaii, with premiums ranging from $13 to $87 per month.As of mid-2020, there were 72,585 people with Medicare in Hawaii who had prescription coverage under stand-alone Medicare Part D plans. Another 128,545 beneficiaries had Medicare Part D coverage go to this web-site integrated with their Medicare Advantage plans, so the majority of Part D coverage in Hawaii is provided via Medicare Advantage plans as opposed to stand-alone Medicare can you buy levitra without a prescription Part D plans (most Medicare Advantage plans include Part D coverage. Stand-alone Medicare Part D plans are usually used to supplement Original Medicare, since it never includes prescription coverage).Medicare Part D enrollment is an option when a person first submits their Medicare application in Hawaii, or can you buy levitra without a prescription when they lose access to other creditable drug coverage (eg, they retire and lose the drug coverage that they had from their employer).
The annual open enrollment period that runs from October 15 to December 7 each year is also an opportunity for Medicare beneficiaries to sign up for a Part D plan or switch to a different Part D plan. Medicare spending in HawaiiAs of 2018, per-beneficiary spending on Medicare in Hawaii was can you buy levitra without a prescription the lowest in the nation, at $6,971. Nationwide, the average was $10,096 (and on the high end, per-beneficiary spending exceeded $11,000 in Florida, Texas, Mississippi, Oklahoma, and Louisiana). Thatâs according to data that were standardized to account for regional differences in payment rates, but the data did can you buy levitra without a prescription not include costs under Medicare Advantage, and Hawaii has a larger-than-average share of its Medicare population enrolled in Medicare Advantage plans.Medicare in Hawaii.
Resources for Medicare beneficiaries and caregiversQuestions about Medicare eligibility in Hawaii or Medicare enrollment in Hawaii?. You can contact the Hawaii State Health Insurance Assistance Program with questions related to Medicare in can you buy levitra without a prescription Hawaii.The state of Hawaiiâs Employer-Union Health Benefits Trust Fund also has an overview of Medicare.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by can you buy levitra without a prescription other health insurance experts.Medicare in Maryland at a glance Medicare enrollment in Maryland The number of Maryland residents with Medicare coverage surpassed one million as of April 2018.
By July 2020, it stood at 1,054,500 â about 17 percent of the stateâs population enrolled in Medicare.87 percent of Marylandâs Medicare beneficiaries are eligible based on their age (ie, they are at least 65 years old), while the other 13 percent are eligible due to a disability that has lasted at least 24 months (people with ALS or end-stage renal disease do not have to wait 24 months for their Medicare coverage to take effect). Nationwide, 85 percent of people filing for Medicare benefits are at least 65 years old, while 15 percent are under 65 and eligible due to disability.Medicare Advantage in MarylandNationwide, about a third of all Medicare beneficiaries were enrolled in private Medicare Advantage plans as of 2018 can you buy levitra without a prescription. But in Maryland, just 11 percent of Medicare beneficiaries selected Medicare can you buy levitra without a prescription Advantage plans. Most of the rest were covered under Original Medicare, but there are also some Maryland Medicare beneficiaries with Medicare Cost plan coverage.By mid-2020, about 13 percent of people with Medicare in Maryland were enrolled in private plans (mostly Medicare Advantage plans, but also some Medicare Cost plans), while the other 87 percent were enrolled in Original Medicare.
At that point, total private plan enrollment among Medicare beneficiaries nationwide had grown to 40 percent, but Medicare Advantage enrollment can you buy levitra without a prescription continues to be less popular in Maryland.The availability of Medicare Advantage plans in Maryland varies from one county to another. In St. Maryâs County, Maryland, there is just one Medicare can you buy levitra without a prescription Advantage plan available in 2020. But in Baltimore County and Montgomery County, there are 24 plans and 20 plans available, respectively.Medicare beneficiaries can switch back and forth from Medicare Advantage to Original Medicare or vice versa each fall during the annual open enrollment period (October 15 through December 7).
There is also a Medicare Advantage open enrollment period (January 1 to March 31) during which people who are already enrolled in Medicare Advantage plans can switch to a different Medicare Advantage plan or drop their Medicare Advantage plan and enroll in Original Medicare instead.Medigap in MarylandMedigap plans are used to supplement Original Medicare, covering some or all of the out-of-pocket costs (for can you buy levitra without a prescription coinsurance and deductibles) that people would otherwise incur if they only had Original Medicare on its own.Medigap plans are standardized under federal rules, with ten different plan options available. In Maryland in 2020, 50 insurers offer Medigap plans, although some only offer a few of the ten plan designs.Under federal rules, Medicare beneficiaries have a six-month window, when they turn 65 and file for benefits under Original Medicare, during which coverage is guaranteed issue for Medigap plans. Federal rules do not, however, guarantee access to a Medigap plan if youâre under 65 and eligible for Medicare as a result of a disability.But Maryland is among the majority of the states that ensure at least some access to Medigap plans for enrollees under the age of can you buy levitra without a prescription 65. In Maryland, Medigap insurers are required to offer Plan A to enrollees who are under 65, on a guaranteed-issue basis if the person applies for the Medigap plan within six months of enrolling in Medicare Part B (insurers are also required to offer Medigap Plan D to beneficiaries, but only if the insurer offers that plan to other enrollees.
Insurers that offer Medigap Plan C must also offer it to disabled Medigap enrollees who were already can you buy levitra without a prescription eligible for Medicare prior to 2020. Under federal rules, Medigap plans C and F cannot be sold to anyone can you buy levitra without a prescription who is newly eligible for Medicare in 2020 or later). The requirement that Medigap insurers offer coverage to disabled beneficiaries is a result of Maryland S.B.48, which took effect in 2017.The premiums are higher for enrollees under age 65, although they are given another enrollment window when they turn 65, so they can then switch to lower-cost Medigap coverage at that point, or pick a plan other than Plan A or C/D. And Maryland does limit the can you buy levitra without a prescription pricing on Medigap Plan A for disabled enrollees.
It cannot exceed the average of the premiums paid for that Plan A by enrollees who are 65 and older.Medicare Part D plans in MarylandOriginal Medicare does not cover outpatient prescription drugs. But Medicare beneficiaries can get prescription coverage via Medicaid (if theyâre qualified by low income and assets), a Medicare Advantage plan, an employer-sponsored plan (offered by a current or former employer), or a stand-alone Part D prescription plan.For can you buy levitra without a prescription 2020 coverage, insurers are offering 27 stand-alone Part D plans available in Maryland, with premiums ranging from $14 to $97 per month.549,075 Maryland Medicare beneficiaries â about 52 percent of the stateâs Medicare population â were enrolled in stand-alone Part D prescription drug plans in Maryland as of July 2020. Nationwide, about 40 percent of all Medicare beneficiaries were enrolled in stand-alone Part D plans.Most Medicare Advantage plans include Part D prescription drug coverage, so stand-alone Part D plans are typically used to supplement Original Medicare. Enrollment in can you buy levitra without a prescription Original Medicare in Maryland is higher than average, which is why stand-alone Medicare Part D enrollment in Maryland is also higher than average.
In addition to the people with stand-alone Part D coverage, nearly 114,000 Medicare beneficiaries in Maryland have Part D coverage as part of their Medicare Advantage coverage. Medicare spending in MarylandIn 2018, Original Medicare spent can you buy levitra without a prescription an average of $10,115 per beneficiary in Maryland, according to data that were standardized to eliminate regional differences in payment rates. The analysis was only based on Original Medicare spending, so it did not include costs for Medicare Advantage enrollees â but Maryland has a much lower-than-average proportion of its Medicare beneficiaries enrolled in Medicare Advantage.The national average Medicare spending that year was $10,096 per enrollee, so Medicare spending in Maryland was virtually the same as the national average. On the extreme ends of the spectrum, Louisiana can you buy levitra without a prescription had the highest average per-enrollee costs, at $11,932, while Hawaii had the lowest, at $6,971.Medicare in Maryland.
Resources for Medicare beneficiaries and their caregiversIf you need help with your Medicare application in Maryland or have general questions about Medicare eligibility in Maryland, you can contact the Maryland Senior Health Insurance Program.The Maryland Insurance Administration has a can you buy levitra without a prescription comprehensive overview of Medigap in Maryland, and a detailed comparison of how Medigap premiums vary by age and insurer in Maryland.The Maryland Health Care Commissionâs Consumer Guide to Long Term Care is also a good resource for people with Medicare who want to understand how theyâll need to prepare for the potential cost of long-term care.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.REDWOOD can you buy levitra without a prescription CITY, Calif., Sept. 01, 2020 (GLOBE NEWSWIRE) -- Guardant Health, Inc.
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How to levitra side effects long term cite this article:Singh OP. Comprehensive Mental Health Action Plan 2013â2030. We must levitra side effects long term 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 Assembly accepted levitra side effects long term 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 levitra side effects long term for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 â 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 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â 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 levitra side effects long term by being involved in general medical care and reduce 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 levitra side effects long term Action Plan 2013-2020. Geneva.
World Health levitra side effects long term Organization. 2013. 2.World Health levitra side effects long term 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 Nov 9];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 â 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 â 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 2019âAugust 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18â65 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 20â30 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 â 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 = â0.42, P = 0.001), followed by TE (r = â0.39, P = 0.002) and least with AE (r = â0.31, 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 mildâmoderate.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]. 1.34â8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI.
2.63â14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09â5.77], 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 âcognitive-affective dissociation of empathyâ 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 â 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 âequally heritable.â 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 âmotivation for changeâ 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].
How to http://markgrigsby.info/how-much-does-lasix-cost cite this article:Singh OP can you buy levitra without a prescription. Comprehensive Mental Health Action Plan 2013â2030. We must rise to the challenge can you buy levitra without a prescription.
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 can you buy levitra without a prescription 2021, the 74th World Health 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 can you buy levitra without a prescription enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 â 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 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â 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 can you buy levitra without a prescription an opportunity for us to expand psychiatry by being involved in general medical care and reduce 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 Plan can you buy levitra without a prescription 2013-2020. Geneva.
World Health Organization can you buy levitra without a prescription. 2013. 2.World Health Organization can you buy levitra without a prescription.
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 Nov 9];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 â 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 â 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 2019âAugust 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18â65 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 20â30 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 â 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 = â0.42, P = 0.001), followed by TE (r = â0.39, P = 0.002) and least with AE (r = â0.31, 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 mildâmoderate.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]. 1.34â8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI.
2.63â14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09â5.77], 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 âcognitive-affective dissociation of empathyâ 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 â 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 âequally heritable.â 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 âmotivation for changeâ 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].