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How to cite this article:Singh OP kamagra oral jelly buy online. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the challenge kamagra oral jelly buy online. 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 the updates to kamagra oral jelly buy online the action plan, including updates to the target options for indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things kamagra oral jelly buy online that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing.

It is an opportunity for us to expand psychiatry by being involved in general medical care and kamagra oral jelly buy online 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 kamagra oral jelly buy online Action Plan 2013-2020. Geneva.

World Health kamagra oral jelly buy online Organization. 2013. 2.World Health Organization kamagra oral jelly buy online. 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 4];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.

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

The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

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

As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment.

Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.

Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

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

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

This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.

Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.

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

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

This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations.

Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

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

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.

Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.

Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

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

An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism.

Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.

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

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

Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3. 14.Krebs D.

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

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

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis.

Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda.

Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

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

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

22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al.

Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders.

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

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

A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J.

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

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

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Over time, Christina’s appointments with the therapist went from every two weeks, to every four weeks, to every five or six. €œTo tell somebody with serious, chronic, disabling depression that they can only see their therapist every five or six weeks is buy kamagra oral jelly like telling somebody with a broken leg that they can only see their physical therapist every five or six weeks,” she said. €œIt’s not enough. It’s not even close to enough.” Then, this summer, Christina was diagnosed with breast cancer.

Everything related to her cancer care — her mammogram, biopsy, surgery appointments — happened promptly (like a buy kamagra oral jelly “well-oiled machine,” she said), while her depression care stumbled along. €œIt is a hot mess,” she said. €œI need to be in therapy — I have cancer!. And still nothing has changed.” A new law signed buy kamagra oral jelly by Gov.

Gavin Newsom in October aims to fix this problem for Californians. Senate Bill 221, which passed the state legislature with a nearly unanimous vote, requires health insurers across the state to reduce wait times buy kamagra oral jelly for mental health care to no more than 10 business days. Six other states — including Colorado, Maryland and Texas — have similar laws limiting wait times. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County.

Across California, half of residents surveyed by the California Health Care buy kamagra oral jelly Foundation in late 2019 said they had to wait too long to see a mental health care provider when they needed one. At Kaiser Permanente, the state’s largest insurance company, 87% of therapists said weekly appointments were not available to patients who needed them, according to a 2020 survey by the National Union of Healthcare Workers, which represents KP therapists — and was the main sponsor of the California wait times legislation. €œIt just feels so unethical,” said triage therapist Brandi Plumley, referring to the typical two-month wait time she sees at Kaiser Permanente’s mental health clinic in Vallejo, east of San Francisco. Every day, she takes multiple crisis calls from patients who have buy kamagra oral jelly therapists assigned to them but can’t get in to see them, she said, describing the providers’ caseloads as “enormous.” “It’s heartbreaking.

And it eats on me day after day after day,” Plumley said. €œWhat Kaiser simply needs to do is hire more clinicians.” Kaiser Permanente says there just aren’t enough therapists out there to hire. KP is an integrated system — it is a health provider and insurance company under one umbrella — and has struggled to buy kamagra oral jelly fill 300 job vacancies in clinical behavioral health, according to a statement from Yener Balan, the insurer’s Northern California vice president of behavioral health. Hiring more clinicians won’t solve the problem, said Balan, who suggested that sustaining one-on-one therapy for all who want it in the future wouldn’t be possible in the current system.

€œWe all must reimagine our approach to the existing national model of care.” Kaiser Permanente lodged concerns about the wait times bill buy kamagra oral jelly when it was introduced. And the trade group representing insurers in the state, the California Association of Health Plans, opposed it, saying the shortage of therapists would make meeting the two-week mandate too difficult. €œThe erectile dysfunction treatment kamagra has only exacerbated this workforce shortage, and demand for these services significantly increased,” said Jedd Hampton, a lobbyist for the California Association of Health Plans, in testimony during a state Senate hearing for the bill in the spring. Hampton referred to a University of buy kamagra oral jelly California-San Francisco study that predicted California would have nearly 30% fewer therapists than needed to meet demand by 2028.

€œSimply put, mandating increased frequency of appointments without addressing the underlying workforce shortage will not lead to increased quality of care,” Hampton said. Lawmakers pushed back. State Sen buy kamagra oral jelly. Scott Wiener (D-San Francisco), who authored the bill, accused insurers of overstating the shortage.

State Sen. Connie Leyva (D-Chino) said that the therapeutic providers are out there but that insurers are responsible for recruiting them into their buy kamagra oral jelly networks by paying higher rates and reducing administrative burdens. If insurers want more young people to enter the mental health care profession, they must improve salaries and working conditions now, said state Sen. Richard Pan buy kamagra oral jelly (D-Sacramento).

(A 2016 KQED investigation uncovered multiple ways that insurers save money by keeping provider networks artificially small.) As bipartisan support for the bill grew in Sacramento, insurers withdrew their formal opposition. But whether other states have the political will, or the resources, to legislate a similar solution is unclear, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy in Washington, D.C. Although California may be able to force insurers to hire more therapists, she said, places like New Mexico, Montana, Wyoming, buy kamagra oral jelly and parts of the South don’t have enough therapists at any price. €œThey don’t have the providers, so you could fine the insurers as much as you want, you’re not going to be able to, in the short term, make up those wait times if they already exist,” she said.

The new California law is a solid step toward improving access to mental health care, with communities of color standing to benefit the most, said Lonnie Snowden, a professor of health policy and management at the University of California-Berkeley. African Americans, Asian Americans and Latinos face the most barriers getting into care, Snowden said, and when buy kamagra oral jelly people of color do come in for treatment, they are more likely to drop out. Oversight and enforcement are needed for the new rules to work, said Keith Humphreys, a psychiatry professor at Stanford University. Kaiser Permanente has data systems that can track the time between appointments, but other insurers set up contracts with therapists in private practice, who manage their own caseloads and schedules.

€œWho would keep track buy kamagra oral jelly of whether people who’ve been seen once were seen again in 10 days, when it’s hard enough just to keep track of how many providers we have and who they are seeing?. € he asked. Questions like that one will fall to state regulators, primarily the California Department of Managed Health Care buy kamagra oral jelly. The department has fined insurers $6.9 million since 2013 for violating state standards, including a $4 million penalty against Kaiser Permanente for excessive wait times for mental health care.

Previous state law required insurers to provide initial mental health care appointments within 10 days, and the new law clarifies that they must do the same for follow-up appointments. Greta Christina, who gets her care at buy kamagra oral jelly a Kaiser Permanente facility, said she is desperate for the new law to start working. It takes effect on July 1, 2022. Christina thought about paying out-of-pocket in the meantime, to find a therapist she could see more often.

But in a cancer crisis, she said, starting over with someone new would be buy kamagra oral jelly too hard. So she’s waiting. €œKnowing that this bill is on the horizon has been helping me hang on,” she said. This story is from a partnership that includes NPR, KQED and KHN.

KHN is not affiliated with Kaiser Permanente. Related Topics Contact Us Submit a Story Tip.

When Greta Christina fell into a deep depression five years ago, she kamagra oral jelly buy online called up her therapist in San Francisco. She’d had a great connection with the provider when she needed therapy in the past. She was delighted to learn that he was now kamagra oral jelly buy online “in network” with her insurance company, meaning she wouldn’t have to pay out-of-pocket anymore to see him.

But her excitement was short-lived. Over time, Christina’s appointments with the therapist went from every two weeks, to every four weeks, to every five or six. €œTo tell somebody with serious, chronic, disabling depression that they can only see their therapist every five or six weeks is like telling somebody with a broken leg that kamagra oral jelly buy online they can only see their physical therapist every five or six weeks,” she said.

€œIt’s not enough. It’s not even close to enough.” Then, this summer, Christina was diagnosed with breast cancer. Everything related to her cancer care — her mammogram, biopsy, surgery appointments — happened kamagra oral jelly buy online promptly (like a “well-oiled machine,” she said), while her depression care stumbled along.

€œIt is a hot mess,” she said. €œI need to be in therapy — I have cancer!. And still nothing has kamagra oral jelly buy online changed.” A new law signed by Gov.

Gavin Newsom in October aims to fix this problem for Californians. Senate Bill 221, which passed the state legislature with a nearly unanimous vote, requires health insurers across the state to reduce wait times for mental health care to no more than 10 business kamagra oral jelly buy online days. Six other states — including Colorado, Maryland and Texas — have similar laws limiting wait times.

EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. Long waits for mental health treatment are a nationwide problem, with reports of patients waiting an average of five or six weeks for care in community clinics, at Department of Veterans Affairs facilities and in private offices from Maryland to Los Angeles County. Across California, half of residents surveyed by the California Health Care Foundation in late 2019 said they had to wait too long to see a mental health care provider when kamagra oral jelly buy online they needed one. At Kaiser Permanente, the state’s largest insurance company, 87% of therapists said weekly appointments were not available to patients who needed them, according to a 2020 survey by the National Union of Healthcare Workers, which represents KP therapists — and was the main sponsor of the California wait times legislation.

€œIt just feels so unethical,” said triage therapist Brandi Plumley, referring to the typical two-month wait time she sees at Kaiser Permanente’s mental health clinic in Vallejo, east of San Francisco. Every day, she takes multiple crisis calls from patients who have therapists assigned to them but can’t get in to see them, she said, describing the providers’ caseloads kamagra oral jelly buy online as “enormous.” “It’s heartbreaking. And it eats on me day after day after day,” Plumley said.

€œWhat Kaiser simply needs to do is hire more clinicians.” Kaiser Permanente says there just aren’t enough therapists out there to hire. KP is an integrated system — it is a health provider and insurance company under one umbrella — and has kamagra oral jelly buy online struggled to fill 300 job vacancies in clinical behavioral health, according to a statement from Yener Balan, the insurer’s Northern California vice president of behavioral health. Hiring more clinicians won’t solve the problem, said Balan, who suggested that sustaining one-on-one therapy for all who want it in the future wouldn’t be possible in the current system.

€œWe all must reimagine our approach to the existing kamagra oral jelly buy online national model of care.” Kaiser Permanente lodged concerns about the wait times bill when it was introduced. And the trade group representing insurers in the state, the California Association of Health Plans, opposed it, saying the shortage of therapists would make meeting the two-week mandate too difficult. €œThe erectile dysfunction treatment kamagra has only exacerbated this workforce shortage, and demand for these services significantly increased,” said Jedd Hampton, a lobbyist for the California Association of Health Plans, in testimony during a state Senate hearing for the bill in the spring.

Hampton referred to a University of California-San Francisco study kamagra oral jelly buy online that predicted California would have nearly 30% fewer therapists than needed to meet demand by 2028. €œSimply put, mandating increased frequency of appointments without addressing the underlying workforce shortage will not lead to increased quality of care,” Hampton said. Lawmakers pushed back.

State Sen kamagra oral jelly buy online. Scott Wiener (D-San Francisco), who authored the bill, accused insurers of overstating the shortage. State Sen.

Connie Leyva (D-Chino) said that the therapeutic providers are out there but that insurers are responsible for recruiting them into their networks by paying higher rates and reducing kamagra oral jelly buy online administrative burdens. If insurers want more young people to enter the mental health care profession, they must improve salaries and working conditions now, said state Sen. Richard Pan kamagra oral jelly buy online (D-Sacramento).

(A 2016 KQED investigation uncovered multiple ways that insurers save money by keeping provider networks artificially small.) As bipartisan support for the bill grew in Sacramento, insurers withdrew their formal opposition. But whether other states have the political will, or the resources, to legislate a similar solution is unclear, said Hemi Tewarson, executive director of the nonpartisan National Academy for State Health Policy in Washington, D.C. Although California may be able to force insurers to hire more therapists, she said, places like New Mexico, Montana, Wyoming, and parts of kamagra oral jelly buy online the South don’t have enough therapists at any price.

€œThey don’t have the providers, so you could fine the insurers as much as you want, you’re not going to be able to, in the short term, make up those wait times if they already exist,” she said. The new California law is a solid step toward improving access to mental health care, with communities of color standing to benefit the most, said Lonnie Snowden, a professor of health policy and management at the University of California-Berkeley. African Americans, Asian Americans and Latinos face the most barriers getting into care, Snowden said, and when people of color do come in for treatment, they are more likely kamagra oral jelly buy online to drop out.

Oversight and enforcement are needed for the new rules to work, said Keith Humphreys, a psychiatry professor at Stanford University. Kaiser Permanente has data systems that can track the time between appointments, but other insurers set up contracts with therapists in private practice, who manage their own caseloads and schedules. €œWho would keep track kamagra oral jelly buy online of whether people who’ve been seen once were seen again in 10 days, when it’s hard enough just to keep track of how many providers we have and who they are seeing?.

€ he asked. Questions like that one kamagra oral jelly buy online will fall to state regulators, primarily the California Department of Managed Health Care. The department has fined insurers $6.9 million since 2013 for violating state standards, including a $4 million penalty against Kaiser Permanente for excessive wait times for mental health care.

Previous state law required insurers to provide initial mental health care appointments within 10 days, and the new law clarifies that they must do the same for follow-up appointments. Greta Christina, who gets her care at a Kaiser Permanente facility, said she is desperate for the new law to kamagra oral jelly buy online start working. It takes effect on July 1, 2022.

Christina thought about paying out-of-pocket in the meantime, to find a therapist she could see more often. But in a cancer crisis, she said, kamagra oral jelly buy online starting over with someone new would be too hard. So she’s waiting.

€œKnowing that this bill is on the horizon has been helping me hang on,” she said. This story is kamagra oral jelly buy online from a partnership that includes NPR, KQED and KHN. KHN is not affiliated with Kaiser Permanente.

Related Topics Contact Us Submit a Story Tip.

Kamagra gold uk

http://www.ec-andre-weckmann-roeschwoog.ac-strasbourg.fr/wp/?page_id=5 Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a kamagra gold uk "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are kamagra gold uk Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.

Under Medicaid managed care. Plan formularies will be comparable to but not the same kamagra gold uk as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy kamagra gold uk Benefit will vary by plan.

Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan. Prescriber Prevails applies in certain drug classes kamagra gold uk. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics.

Prescribers will need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation kamagra gold uk. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider kamagra gold uk organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013.

Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS kamagra gold uk TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within the first 90 days kamagra gold uk of joining a health plan.

After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause. The pharmacy benefit changes are not considered good kamagra gold uk cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.

If the plan still denies access, consumers can pursue review processes specific to managed care while at the kamagra gold uk same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures for drug denials. Information on these procedures should be provided in member kamagra gold uk handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision.

An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial kamagra gold uk FAD Notice and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up kamagra gold uk to 14 days if more information is needed and it is in the enrollee's interest.

AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here kamagra gold uk. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience kamagra gold uk problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a kamagra gold uk generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the eMedNY website.

Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original prescriptions, not kamagra gold uk refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process. The New York State Board of Pharmacy kamagra gold uk publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities.

The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs. Click here to kamagra gold uk view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

1-800-206-8125 (Mon kamagra gold uk. - Fri. 8:30 am - 4:30 pm) NY State Department of Insurance. 1-800-400-8882 NY State Attorney General's kamagra gold uk Health Care Bureau. 1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State.

2019 updates - The Trump administration has taken steps to end TPS status. Two courts kamagra gold uk have temporarily enjoined the termination of TPS, one in New York State in April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS. See US Immigration Website on TPS - General TPS website with links to status in all countries, including HAITI. See also Pew kamagra gold uk Research March 2019 article.

Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019. Read more about this change in public charge rules here. What is Temporary kamagra gold uk Protected Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely. On January 21, 2010 the United States determined that individuals from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12.

TPS gives undocumented Haitian residents, who were kamagra gold uk living in the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally. It is important to note that the U.S. Grants TPS to individuals from other kamagra gold uk countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia and Sudan. TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs.

In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing Under Color of Law) for purposes of medical assistance eligibility and thus meet the immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program. Nearly all children in New York remain eligible for Child Health Plus kamagra gold uk including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart. Where to Apply What to BringIndividuals who have applied for TPS will need to bring several documents to prove their eligibility for public health insurance. Individuals will need to bring kamagra gold uk.

1) Proof of identity. 2) Proof of residence in New York. 3) Proof kamagra gold uk of income. 4) Proof of application for TPS. 5) Proof that U.S.

Citizenship and Immigration Services (USCIS) has kamagra gold uk received the application for TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand. All Medicaid offices and enrollers are required to offer free translation and interpretation services to anyone who cannot communicate effectively in English. A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided kamagra gold uk in all interactions with the office. Important documents, such as Medicaid applications, should be translated either orally or in writing.

Interpreter services must be offered free of charge, and applicants requiring interpreter services must not be made to wait unreasonably longer than English speaking applicants. An applicant must never be asked kamagra gold uk to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status. A copy of the list is posted at the NYIC’s website at http://www.thenyic.org. o USCIS TPS website with links to status in all countries, including HAITI.

O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays. 9:30 am - 12:30 pm FOR IMMIGRATION HELP. CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m. To 8:00 p.m.Saturday-Sunday, from 9:00 a.m.

To 5:00 p.m. Or call toll-free in New York State at 1-800-566-7636 Please see these fact sheets and web sites of national organizations for more information about the new PUBLIC CHARGE rules. Printable Fact Sheets for Distribution This article was co-authored by the New York Immigration Coalition, Empire Justice Center and the Health Law Unit of the Legal Aid Society.

At that kamagra oral jelly buy online time, this drug benefit was "carved into" the Medicaid managed can you buy kamagra without a prescription care benefit package. Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans.

That means that members of kamagra oral jelly buy online managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.

Under Medicaid managed kamagra oral jelly buy online care. Plan formularies will be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary.

Plan kamagra oral jelly buy online formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy Benefit will vary by plan. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy.

Pharmacy networks kamagra oral jelly buy online can also differ from plan to plan. Prescriber Prevails applies in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes.

atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic kamagra oral jelly buy online therapeutics. Prescribers will need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies.

The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near kamagra oral jelly buy online future. Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013.

Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long kamagra oral jelly buy online as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time.

Medicaid consumers will have this option kamagra oral jelly buy online only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year.

Consumers can switch plans during kamagra oral jelly buy online the “lock in” period only for good cause. The pharmacy benefit changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time.

STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE kamagra oral jelly buy online PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements. If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials.

Some plans may develop special procedures kamagra oral jelly buy online for drug denials. Information on these procedures should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision.

An adverse decision is called a 'FInal Adverse Determination" or kamagra oral jelly buy online FAD. See model Denial FAD Notice and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD.

The enrollee may only request a fair hearing BEFORE receiving the kamagra oral jelly buy online FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing.

The enrollee must request the Plan Appeal and kamagra oral jelly buy online then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care.

Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their kamagra oral jelly buy online medications. Consumers who experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees.

Certain kamagra oral jelly buy online drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the eMedNY website.

Even in fee for kamagra oral jelly buy online service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months.

Click here for kamagra oral jelly buy online more information on NY's prior authorization process. The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program.

Click here to search for a specific drug from the most frequently prescribed kamagra oral jelly buy online drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs. Click here to view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline.

1-888-614-5400 NY kamagra oral jelly buy online State Department of Health's Managed Care Hotline. 1-800-206-8125 (Mon. - Fri.

8:30 am - 4:30 pm) kamagra oral jelly buy online NY State Department of Insurance. 1-800-400-8882 NY State Attorney General's Health Care Bureau. 1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State.

2019 updates - kamagra oral jelly buy online The Trump administration has taken steps to end TPS status. Two courts have temporarily enjoined the termination of TPS, one in New York State in April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS.

See US kamagra oral jelly buy online Immigration Website on TPS - General TPS website with links to status in all countries, including HAITI. See also Pew Research March 2019 article. Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019.

Read more about kamagra oral jelly buy online this change in public charge rules here. What is Temporary Protected Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely.

On January 21, 2010 the United States kamagra oral jelly buy online determined that individuals from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12. TPS gives undocumented Haitian residents, who were living in the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally.

It is important to note kamagra oral jelly buy online that the U.S. Grants TPS to individuals from other countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia and Sudan. TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs.

In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing kamagra oral jelly buy online Under Color of Law) for purposes of medical assistance eligibility and thus meet the immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program. Nearly all children in New York remain eligible for Child Health Plus including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart.

Where to Apply What to BringIndividuals who have applied for TPS will need to bring several documents to prove kamagra oral jelly buy online their eligibility for public health insurance. Individuals will need to bring. 1) Proof of identity.

2) Proof of residence in kamagra oral jelly buy online New York. 3) Proof of income. 4) Proof of application for TPS.

5) kamagra oral jelly buy online Proof that U.S. Citizenship and Immigration Services (USCIS) has received the application for TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand.

All Medicaid offices and enrollers are required to offer free translation and interpretation services to kamagra oral jelly buy online anyone who cannot communicate effectively in English. A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided in all interactions with the office. Important documents, such as Medicaid applications, should be translated either orally or in writing.

Interpreter services must be offered free of charge, and applicants requiring interpreter services must not be made to wait unreasonably longer kamagra oral jelly buy online than English speaking applicants. An applicant must never be asked to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status.

A copy of the list kamagra oral jelly buy online is posted at the NYIC’s website at http://www.thenyic.org. o USCIS TPS website with links to status in all countries, including HAITI. O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays.

9:30 am - 12:30 pm FOR IMMIGRATION kamagra oral jelly buy online HELP. CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m.

To 8:00 p.m.Saturday-Sunday, from 9:00 a.m. To 5:00 p.m. Or call toll-free in New York State at 1-800-566-7636 Please see these fact sheets and web sites of national organizations for more information about the new PUBLIC CHARGE rules.

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Acute coronary syndrome due to spontaneous coronary artery dissection (SCAD) typically is managed conservatively because coronary anatomy returns to normal in most patients at follow-up and because there is a high rate of technical failure kamagra oral jelly uk and complications with percutaneous coronary intervention (PCI). However, a subgroup of kamagra oral jelly uk these patients is at risk of extensive myocardial infarction and might benefit from PCI, despite the risk of complications. In this issue of Heart, Kotecha and colleagues1 report outcomes in 215 SCAD patients (94% women, median kamagra oral jelly uk age 48 years with a range of 42–54 years) who underwent PCI for ST-elevation myocardial infarction, cardiac arrest, TIMI grade 0/1 flow or proximal dissection (figure 1). As expected, PCI-related complications were frequent, occurring in 38.6% (83/215), with 13.0% (28/215) of patients suffering a serious complication. Even so, improved TIMI flow was achieved in 84.3% (118/140) with worsened TIMI kamagra oral jelly uk flow in only 7% of patients.

At a median follow-up of 900 days, 9.3% suffered recurrent acute myocardial infarction, 4.7% required further revascularisation, 1.5% had a stroke and kamagra oral jelly uk 1.4% died. However, there was no difference in outcomes in SCAD-PCI patients compared with a matched cohort of SCAD patients who did not undergo PCI.Details of the PCI procedure in SCAD intervention patients (n=215). (A) interventional strategy, (B) number of stents deployed, (C) stent length compared with kamagra oral jelly uk lesion length and (D) coronary heat map of stented AHA coronary segments. AHA, American kamagra oral jelly uk Heart Association. PCI, percutaneous coronary intervention.

SCAD, spontaneous kamagra oral jelly uk coronary artery dissection." data-icon-position data-hide-link-title="0">Figure 1 Details of the PCI procedure in SCAD intervention patients (n=215). (A) interventional strategy, (B) number of stents deployed, (C) stent length compared with lesion length and (D) coronary heat kamagra oral jelly uk map of stented AHA coronary segments. AHA, American Heart Association. PCI, percutaneous kamagra oral jelly uk coronary intervention. SCAD, spontaneous coronary artery dissection.Adamson2 reminds us that SCAD may account for as many as 2%–3% of acute coronary syndromes and predominantly kamagra oral jelly uk affects middle-aged women without traditional risk factors for coronary disease.

He also points out that in the study by Kotecha and colleagues1 the SCAD patients undergoing PCI, compared with those treated conservatively, more often suffered myocardial infarction or cardiac arrest and more often had left main or proximal left anterior descending coronary artery involvement, reflecting selection of patients in whom the risks of PCI were offset by the severity of the coronary involvement. He concludes kamagra oral jelly uk. €˜Excellent outcomes for most conservatively managed patients suggest our default should be to kamagra oral jelly uk ‘do no harm’. But, for an important minority kamagra oral jelly uk where intervention is deemed a true necessity—complete vessel occlusion, haemodynamic instability—we ought to take courage that there is scope ‘to do good’.’The effectiveness of angiotensin receptor-neprilysin inhibitor (ARNI) treatment versus renin–angiotensin system (RAS) blockade alone was evaluated by Desai and colleagues3 in a cohort of over 50 000 older (average age 76 years) adults with heart failure due to reduced ejection fraction (HFrEF). Patients treated with an ARNI, compared with RAS blockade alone, had a lower 1-year cumulative incidence of the composite outcome of worsening HF events or all-cause mortality both those in whom ARNI was the initial treatment (‘initiators’, 27.2% vs 26.9%) and among those who switched from RAS blockade to ARNI treatment (‘switchers’, 23.8% vs 29.7%), even after adjustment for numerous pre-exposure characteristics (figure 2).Cumulative incidence of individual endpoints of worsening heart failure and all-cause mortality after propensity score weighting in patients treated with angiotensin receptor-neprilysin inhibitor (ARNI) or renin–angiotensin system blockade alone.

Numbers in the table kamagra oral jelly uk below the plot represent populations at risk under as-treated follow-up. ARB, angiotensin receptor blocker." data-icon-position data-hide-link-title="0">Figure 2 Cumulative incidence of individual endpoints of worsening heart failure and kamagra oral jelly uk all-cause mortality after propensity score weighting in patients treated with angiotensin receptor-neprilysin inhibitor (ARNI) or renin–angiotensin system blockade alone. Numbers in the table below the plot represent populations at risk under as-treated follow-up. ARB, angiotensin receptor blocker.In the accompanying editorial, Griffin and Cheng4 put this real-world data into the context of previous kamagra oral jelly uk clinical trials. For example, mean age in kamagra oral jelly uk the current study was older compared with clinical trials (76 vs 64 years), more women (33% vs 21%) and black patients (11% vs 5%) were included, and a sizeable number (12%–14%) had chronic kidney disease.

They also point out that the ‘switcher’ group likely represents more chronic HF compared with the ‘initiator’ group, possibly explaining the apparent greater effect in the “switcher group”. However, in the ‘real world’ most patients kamagra oral jelly uk eligible for an ARNI still do not receive this mediation despite guideline recommendations that ‘ARNI is now indicated in patients with chronic heart failure regardless of ejection fraction’, highlighting the barriers to uptake including lack of physician education, concerns about safety of switching medications, particularly the effects on blood pressure, and the cost of the drug for patients. Griffin and Cheng conclude ‘As we continue to evaluate efficacy of new indications for ARNI therapy and the focus turns to HF with mid-range and preserved EF, we must continue kamagra oral jelly uk to improve morbidity and mortality in HFrEF by making it available to those in whom it already has proven benefit.’In another interesting paper in this issue of Heart, Kaiser and colleagues5 looked at the association between serum lipoprotein(a) (Lp(a)) levels and the prevalence and quantity of aortic valve calcium (AVC), measured by cardiac CT, in 2412 participants in the population-based Rotterdam Study as well as 859 healthy individuals from the Amsterdam University Medical Centers (UMC) outpatient clinics. In both cohorts, higher Lp(a) levels were associated with higher valve calcium scores although the prevalence of AVC was 33.1% in the Rotterdam Study versus 5.4% in the Amsterdam UMC cohort (figure 3).0. The prevalence of aortic valve calcium for kamagra oral jelly uk lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for ages 65–74 and 78 of 123 (63.4%) vs 197 of 387 (50.9%) for ages 75 and over.

Error bars indicate 95% CIs." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-999769262" data-figure-caption="Prevalence of aortic valve calcium stratified by age and lipoprotein(a) kamagra oral jelly uk. Aortic valve calcium was defined as an aortic valve Agatston score >0. The prevalence of aortic valve calcium for lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for kamagra oral jelly uk ages 65–74 and 78 of 123 (63.4%) vs 197 of 387 (50.9%) for ages 75 and over. Error bars kamagra oral jelly uk indicate 95% CIs." data-icon-position data-hide-link-title="0">Figure 3 Prevalence of aortic valve calcium stratified by age and lipoprotein(a). Aortic valve calcium was defined as an aortic valve Agatston score >0.

The prevalence of aortic valve calcium for lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for kamagra oral jelly uk ages 65–74 and 78 of 123 (63.4%) vs 197 of 387 (50.9%) for ages 75 and over. Error bars indicate kamagra oral jelly uk 95% CIs.Tzolos and Dweck6 succinctly summarise the key finding of this study. €˜Once again, Lp(a) appears associated kamagra oral jelly uk with incident AS and the initiation phase of the disease. Interestingly, there appears to be a threshold effect underlying this association around the 80th percentile (47.7 mg/dL).’ They emphasise that this data is important because ‘In order to adequately power future randomised controlled trials, we need to target the patients who might benefit most from an intervention. This study suggests that Lp(a) lowering should target patients above the 80th Lp(a) percentile (≥50 mg/dL) independent of their age.’ However, ‘Ultimately, double-blinded randomised controlled trials are required to assess whether Lp(a) lowering in patients with aortic valve calcification can slow disease progression and improve clinical outcomes.’The Education in Heart article in this issue reviews the challenging issue of weight loss kamagra oral jelly uk through lifestyle changes for primary prevention of cardiovascular disease.

Yannakoulia and Panagiotakos7 acknowledge the difficulty in helping patients improve dietary kamagra oral jelly uk patterns and engage in regular exercise, as well as the high prevalence of weight regaining even when initial weight loss efforts are successful. The Mediterranean diet/lifestyle has the most scientific evidence establishing benefits and as summarised in the article (figure 4).Mediterranean lifestyle, weight and energy balance, in relation to cardiovascular disease risk. MUFA,monounsaturated fatty kamagra oral jelly uk acids. PUFA, polyunsaturated fatty acids." data-icon-position data-hide-link-title="0">Figure 4 Mediterranean lifestyle, kamagra oral jelly uk weight and energy balance, in relation to cardiovascular disease risk. MUFA,monounsaturated fatty acids.

PUFA, polyunsaturated fatty acids.The Cardiology in Focus article in this issue of Heart provides useful guidance for medical students, residents or cardiology trainees interested in pursing a career in kamagra oral jelly uk preventative cardiology.8Ethics statementsPatient consent for publicationNot required.Congenital heart diseases (CHD) are a heterogeneous group of conditions that afflict an increasing number of adults. On some kamagra oral jelly uk occasions, the singularities of the anatomy and physiology are a real challenge for the treating cardiologist. Such is the case of patients with congenitally corrected transposition of the great arteries (ccTGA) and those with transposition of the great arteries (TGA) repaired with the atrial switch procedure, in which a morphologically right ventricle (RV) sustains the systemic circulation. Although there are case reports kamagra oral jelly uk of asymptomatic elderly patients being diagnosed with previously undetected ccTGA, these are exceptions. The systemic right ventricle (SRV) usually experiences a progressive decline in kamagra oral jelly uk the systolic function ultimately leading to death or heart transplantation in most cases.The Achilles’ heel of the SRV researchAvailable drug strategies for the treatment of the failing left ventricle (LV) in acquired heart disease are commonly used in the SRV dysfunction, but such approach is not based on scientific evidence.

Several studies have unsuccessfully tried to prove a net benefit from the use of beta blockers or agents targeting the renin-angiotensin-aldosterone system (RAAS) in patients with biventricular circulation and an SRV. Even a few randomised controlled trials (RCT), the top method in the hierarchy of scientific evidence, have failed in this purpose.1 There are different reasons that could explain this lack of success, the most important kamagra oral jelly uk being the small sample size of all the studies. The largest kamagra oral jelly uk RCT2 only included 88 patients (44 randomised to valsartan and 44 to placebo). Considering that the Survival And Ventricular Enlargement ….

Acute coronary syndrome due to spontaneous coronary artery dissection (SCAD) typically is managed conservatively because coronary anatomy kamagra oral jelly buy online returns to normal in most patients at follow-up and because there is a high rate of technical failure and complications with percutaneous coronary intervention (PCI). However, a subgroup of these patients is at risk of extensive myocardial infarction and kamagra oral jelly buy online might benefit from PCI, despite the risk of complications. In this issue kamagra oral jelly buy online of Heart, Kotecha and colleagues1 report outcomes in 215 SCAD patients (94% women, median age 48 years with a range of 42–54 years) who underwent PCI for ST-elevation myocardial infarction, cardiac arrest, TIMI grade 0/1 flow or proximal dissection (figure 1).

As expected, PCI-related complications were frequent, occurring in 38.6% (83/215), with 13.0% (28/215) of patients suffering a serious complication. Even so, improved TIMI flow was kamagra oral jelly buy online achieved in 84.3% (118/140) with worsened TIMI flow in only 7% of patients. At a median follow-up of 900 days, 9.3% suffered recurrent acute myocardial infarction, 4.7% required further revascularisation, 1.5% kamagra oral jelly buy online had a stroke and 1.4% died.

However, there was no difference in outcomes in SCAD-PCI patients compared with a matched cohort of SCAD patients who did not undergo PCI.Details of the PCI procedure in SCAD intervention patients (n=215). (A) interventional strategy, (B) number kamagra oral jelly buy online of stents deployed, (C) stent length compared with lesion length and (D) coronary heat map of stented AHA coronary segments. AHA, American Heart Association kamagra oral jelly buy online.

PCI, percutaneous coronary intervention. SCAD, spontaneous coronary artery dissection." data-icon-position data-hide-link-title="0">Figure 1 Details of the kamagra oral jelly buy online PCI procedure in SCAD intervention patients (n=215). (A) interventional strategy, (B) number of stents deployed, (C) stent length compared with lesion length and (D) coronary heat map kamagra oral jelly buy online of stented AHA coronary segments.

AHA, American Heart Association. PCI, percutaneous coronary kamagra oral jelly buy online intervention. SCAD, spontaneous coronary artery dissection.Adamson2 reminds us that SCAD may account for as many kamagra oral jelly buy online as 2%–3% of acute coronary syndromes and predominantly affects middle-aged women without traditional risk factors for coronary disease.

He also points out that in the study by Kotecha and colleagues1 the SCAD patients undergoing PCI, compared with those treated conservatively, more often suffered myocardial infarction or cardiac arrest and more often had left main or proximal left anterior descending coronary artery involvement, reflecting selection of patients in whom the risks of PCI were offset by the severity of the coronary involvement. He concludes kamagra oral jelly buy online. €˜Excellent outcomes for most conservatively managed patients suggest our default should be to ‘do no kamagra oral jelly buy online harm’.

But, for an important minority where intervention is deemed a true necessity—complete vessel occlusion, haemodynamic instability—we ought to take courage kamagra oral jelly buy online that there is scope ‘to do good’.’The effectiveness of angiotensin receptor-neprilysin inhibitor (ARNI) treatment versus renin–angiotensin system (RAS) blockade alone was evaluated by Desai and colleagues3 in a cohort of over 50 000 older (average age 76 years) adults with heart failure due to reduced ejection fraction (HFrEF). Patients treated with an ARNI, compared with RAS blockade alone, had a lower 1-year cumulative incidence of the composite outcome of worsening HF events or all-cause mortality both those in whom ARNI was the initial treatment (‘initiators’, 27.2% vs 26.9%) and among those who switched from RAS blockade to ARNI treatment (‘switchers’, 23.8% vs 29.7%), even after adjustment for numerous pre-exposure characteristics (figure 2).Cumulative incidence of individual endpoints of worsening heart failure and all-cause mortality after propensity score weighting in patients treated with angiotensin receptor-neprilysin inhibitor (ARNI) or renin–angiotensin system blockade alone. Numbers in the table below the plot kamagra oral jelly buy online represent populations at risk under as-treated follow-up.

ARB, angiotensin receptor blocker." data-icon-position data-hide-link-title="0">Figure 2 Cumulative incidence of individual endpoints of worsening heart failure and all-cause kamagra oral jelly buy online mortality after propensity score weighting in patients treated with angiotensin receptor-neprilysin inhibitor (ARNI) or renin–angiotensin system blockade alone. Numbers in the table below the plot represent populations at risk under as-treated follow-up. ARB, angiotensin receptor blocker.In the accompanying editorial, Griffin and Cheng4 kamagra oral jelly buy online put this real-world data into the context of previous clinical trials.

For example, kamagra oral jelly buy online mean age in the current study was older compared with clinical trials (76 vs 64 years), more women (33% vs 21%) and black patients (11% vs 5%) were included, and a sizeable number (12%–14%) had chronic kidney disease. They also point out that the ‘switcher’ group likely represents more chronic HF compared with the ‘initiator’ group, possibly explaining the apparent greater effect in the “switcher group”. However, in the ‘real world’ most patients eligible for an ARNI still do not receive this mediation despite guideline recommendations that kamagra oral jelly buy online ‘ARNI is now indicated in patients with chronic heart failure regardless of ejection fraction’, highlighting the barriers to uptake including lack of physician education, concerns about safety of switching medications, particularly the effects on blood pressure, and the cost of the drug for patients.

Griffin and Cheng conclude ‘As we continue to evaluate efficacy of new indications for ARNI therapy and the focus turns to HF with mid-range and preserved EF, we must continue to improve morbidity and mortality in HFrEF by making it available to those in whom it already has proven benefit.’In another interesting paper in this issue of Heart, Kaiser and colleagues5 looked at the association kamagra oral jelly buy online between serum lipoprotein(a) (Lp(a)) levels and the prevalence and quantity of aortic valve calcium (AVC), measured by cardiac CT, in 2412 participants in the population-based Rotterdam Study as well as 859 healthy individuals from the Amsterdam University Medical Centers (UMC) outpatient clinics. In both cohorts, higher Lp(a) levels were associated with higher valve calcium scores although the prevalence of AVC was 33.1% in the Rotterdam Study versus 5.4% in the Amsterdam UMC cohort (figure 3).0. The prevalence of aortic valve calcium kamagra oral jelly buy online for lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for ages 65–74 and 78 of 123 (63.4%) vs 197 of 387 (50.9%) for ages 75 and over.

Error bars indicate 95% CIs." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-999769262" data-figure-caption="Prevalence of aortic valve calcium kamagra oral jelly buy online stratified by age and lipoprotein(a). Aortic valve calcium was defined as an aortic valve Agatston score >0. The prevalence of aortic valve calcium for lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for ages 65–74 and 78 of 123 (63.4%) kamagra oral jelly buy online vs 197 of 387 (50.9%) for ages 75 and over.

Error bars indicate 95% CIs." data-icon-position data-hide-link-title="0">Figure kamagra oral jelly buy online 3 Prevalence of aortic valve calcium stratified by age and lipoprotein(a). Aortic valve calcium was defined as an aortic valve Agatston score >0. The prevalence of aortic valve calcium for lipoprotein(a) above and below the 80th percentile (47.7 mg/dL), respectively, was 1 of 67 (1.5%) vs kamagra oral jelly buy online 3 of 339 (0.9%) for ages below 45, 6 of 38 (15.8%) vs 9 of 210 (4.3%) for ages 45–54, 43 of 179 (24.0%) vs 96 of 676 (14.2%) for ages 55–64, 116 of 247 (47.0%) vs 295 of 1005 (29.4%) for ages 65–74 and 78 of 123 (63.4%) vs 197 of 387 (50.9%) for ages 75 and over.

Error bars indicate 95% CIs.Tzolos and Dweck6 succinctly summarise the key finding of this kamagra oral jelly buy online study. €˜Once again, Lp(a) appears associated with incident AS and the initiation kamagra oral jelly buy online phase of the disease. Interestingly, there appears to be a threshold effect underlying this association around the 80th percentile (47.7 mg/dL).’ They emphasise that this data is important because ‘In order to adequately power future randomised controlled trials, we need to target the patients who might benefit most from an intervention.

This study suggests that Lp(a) lowering should target patients above the 80th Lp(a) percentile (≥50 mg/dL) independent of their age.’ However, ‘Ultimately, double-blinded randomised controlled trials are required to assess whether Lp(a) lowering in patients with aortic valve calcification kamagra oral jelly buy online can slow disease progression and improve clinical outcomes.’The Education in Heart article in this issue reviews the challenging issue of weight loss through lifestyle changes for primary prevention of cardiovascular disease. Yannakoulia and Panagiotakos7 acknowledge the difficulty in kamagra oral jelly buy online helping patients improve dietary patterns and engage in regular exercise, as well as the high prevalence of weight regaining even when initial weight loss efforts are successful. The Mediterranean diet/lifestyle has the most scientific evidence establishing benefits and as summarised in the article (figure 4).Mediterranean lifestyle, weight and energy balance, in relation to cardiovascular disease risk.

MUFA,monounsaturated fatty kamagra oral jelly buy online acids. PUFA, polyunsaturated fatty kamagra oral jelly buy online acids." data-icon-position data-hide-link-title="0">Figure 4 Mediterranean lifestyle, weight and energy balance, in relation to cardiovascular disease risk. MUFA,monounsaturated fatty acids.

PUFA, polyunsaturated fatty acids.The Cardiology in Focus article in this issue of Heart provides useful guidance for medical students, residents or cardiology trainees interested in pursing a career kamagra oral jelly buy online in preventative cardiology.8Ethics statementsPatient consent for publicationNot required.Congenital heart diseases (CHD) are a heterogeneous group of conditions that afflict an increasing number of adults. On some occasions, the singularities of the anatomy and physiology are a kamagra oral jelly buy online real challenge for the treating cardiologist. Such is the case of patients with congenitally corrected transposition of the great arteries (ccTGA) and those with transposition of the great arteries (TGA) repaired with the atrial switch procedure, in which a morphologically right ventricle (RV) sustains the systemic circulation.

Although there kamagra oral jelly buy online are case reports of asymptomatic elderly patients being diagnosed with previously undetected ccTGA, these are exceptions. The systemic right ventricle (SRV) usually experiences a progressive decline in the systolic function ultimately leading to kamagra oral jelly buy online death or heart transplantation in most cases.The Achilles’ heel of the SRV researchAvailable drug strategies for the treatment of the failing left ventricle (LV) in acquired heart disease are commonly used in the SRV dysfunction, but such approach is not based on scientific evidence. Several studies have unsuccessfully tried to prove a net benefit from the use of beta blockers or agents targeting the renin-angiotensin-aldosterone system (RAAS) in patients with biventricular circulation and an SRV.

Even a few randomised controlled trials (RCT), the top method in the hierarchy of scientific evidence, have failed in this kamagra oral jelly buy online purpose.1 There are different reasons that could explain this lack of success, the most important being the small sample size of all the studies. The largest RCT2 only included 88 patients (44 randomised to valsartan and 44 to kamagra oral jelly buy online placebo). Considering that the Survival And Ventricular Enlargement ….