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Â out of the subconscious to the forefront is precisely the premise of this zithromax online without prescription article. The main aim is to profess the love I have for the subject and in this endeavour I hope it serves as a guiding tool for the various graduates who have an inclination towards the field of urology. The article talks about what sort of personality traits make up a urologist and the various factors to be considered before taking up this branch of surgical medicine as a career option.The idea to write this article slowly began taking root as I reminisced about what led to my current career path and my love for urology.

So what was it so attractive about âurologyâ, that I zithromax online without prescription was drawn towards it?. What made me take up this branch of surgery for the rest of my life?. Was it the versatility of surgeries involved, with a perfect blend of open, endoscopic and laparoscopic procedures?.

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It was a little bit of everything. A pinch of money, a dash of surgeries, a smidgen of respect and a whole lot of life thrown in, and voila you zithromax online without prescription had a perfect recipe. Urology seemed like a perfect amalgamation.Every â¦IntroductionIn the previous decades, distance learning in (medical) education, has taken flight worldwide.

Many medical educational institutions have successfully embraced online distance learning (ODL), with online courses now being delivered by a great number of organisations, ranging from community colleges to renowned universities all around the globe.1â4 The current era of physical distancing in light of the buy antibiotics zithromax has further underscored the need for online learning programmes for healthcare professionals. Although some medical educators with a degree in teaching may have abundant experience in developing and hosting online training programmes (eg, ODL postgraduate programmes), many clinical teachers, for example, physicians, nurses and other allied healthcare professionals, may feel quite hesitant and out of their depth when faced with the request to provide their lectures or trainings online instead of face to face.

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This extra rest can be helpful in decreasing stress http://performanceandpolitics.aber.ac.uk/about/postgraduate-programmes/ on the shoulder can you buy zithromax and elbow joints, but it can also lead to decreased strength and ROM. Overhead athletes need to keep their bodies strong, and a great way to achieve that is by performing a regular strengthening program. With many gyms remaining closed or limiting access during social distancing, that can be even more challenging. However, there are many exercises that can can you buy zithromax be done at home with minimal equipment needs.

A great program to focus on during the off season is the Throwerâs Ten program that was developed with the overhead athlete in mind. These exercises focus on the muscle groups that matter most for the overhead athlete. We use can you buy zithromax our entire body to throw a ball and the stress on the shoulder to decelerate the arm is about twice our body weight. Most of this stress gets placed on the rotator cuff and scapular muscles that slow the arm down as we follow through with our throw.

Weakness in these muscles can lead to problems with the shoulder and elbow joints. Common injuries can be Little League shoulder and elbow or strains to the ulnar can you buy zithromax collateral ligaments (Tommy John). If you have dealt with pain or injuries in the past, a comprehensive evaluation by a physical therapist (PT) who focuses on treating the overhead athlete can be extremely helpful in identifying areas of concern. Your PT will evaluate your strength with a dynamometer to look at any significant abnormalities between shoulders.

They can also perform a video throwing analysis to look at can you buy zithromax ways to potentially reduce injury risk and improve performance. This can almost always be achieved with only a couple of visits, and the off season is a great time to start addressing areas of concern to be ready for next season or throwing during the winter. Your PT can help you develop a customized home exercise program based on your needs. Physical can you buy zithromax Therapist Kyle Stevenson, D.P.T., sees patients at MidMichiganâs Rehabilitation Services location in Greater Midland North-End Fitness Center.

He has a special interest in sports medicine, and enjoys working with athletes of all ages. He has completed specialized coursework and training for the throwing athletes. New patients are welcome with a can you buy zithromax physician referral by calling (989) 832-5913. Those who would like more information about MidMichiganâs Rehabilitation Services may visit www.midmichigan.org/rehabilitation.Have you ever woken up with a sore throat and used your phone to get a virtual visit?.

The odds are itâs not available to you, and there is a reason for that. You may can you buy zithromax be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during buy antibiotics and how health systems are offering virtual access like never before. Thereâs a reason for that, too. For the past few weeks Iâve seen Facebook posts daily from former nursing colleagues in metro Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with buy antibiotics.

It makes me very proud to call these nurses my can you buy zithromax friends. As a former emergency department nurse, I recall the feeling of satisfaction knowing that Iâve helped someone on the worst day of their life. One of the best parts of being a nurse is knowing you matter to the only person in health care that truly matters. The patient can you buy zithromax.

Several years ago I made the difficult decision to no longer perform bedside nursing and become a nurse administrator. The biggest loss from my transition is the feeling that what I do matters to the patient. buy antibiotics has forced a lot of us to rethink the role we play in health care and what the real can you buy zithromax priority should be. Things that were top priorities three months ago have been rightfully cast aside to either care for patients in a zithromax or prepare for the unknown future of, âWhen is our turn?.

Â For me, buy antibiotics has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront of care during this crisis. It has can you buy zithromax also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently. When I became the director of virtual care at our organization in 2015 I knew nothing about telehealth. Sure, I had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company lets them FaceTime a doctor for free (spoiler alert.

Itâs not FaceTime) can you buy zithromax. I was tech-savvy from a consumer perspective and a tech novice from an IT perspective. Nevertheless, my team and I spent the next few years learning as we built one of the higher volume virtual care networks in the state of Michigan. We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around can you buy zithromax those barriers.

But, there were two obstacles that we could not overcome. Government regulation and insurance provider willingness to cover virtual visits. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which can you buy zithromax I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home. The need to social distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place created instant demand for direct-to-consumer virtual care.

In all honesty, Iâve always considered direct-to-consumer virtual care to be the flashy, must-have holiday gift of the year that organizations are convinced will be the way of the future. If a health system wants to provide on-demand access to patients can you buy zithromax for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health systemâs logo on it. What a health system will struggle with is to find is enough patient demand to cover the high cost. Remember my friends from earlier that told me about the app their insurance gave them?.

Nearly all of them followed that up can you buy zithromax by telling me theyâve never actually used it. I am fortunate that I work for an organization that understands this and instead focuses on how can we provide care that our patients actually want and need from the doctors they want to see. Ironically, this fiscal year we had a corporate top priority around direct-to-consumer virtual care. We wanted to expand what we thought were some can you buy zithromax successful pilots and perform 500 direct-to-consumer visits.

This year has been one of the hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority. With only four months left, we how much does zithromax cost per pill were only about halfway there. The biggest problem we ran into was that every great idea a physician brought to me was instantly dead in the water because practically no insurance company would pay for it. There are (prior to buy antibiotics) a plethora of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a can you buy zithromax health care facility.

It is extremely limited what will be paid for in the patient home and most of it is so specific that the average patient isnât eligible to get any in-home virtual care. Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would be covered if it happened in office. Add to that the massive capital and operating expenses it takes can you buy zithromax to build a virtual care network and you can see why these programs donât exist. A month ago I was skeptical weâd have a robust direct-to-consumer program any time soon and then buy antibiotics hit.

When buy antibiotics started to spread rapidly in the United States, regulations and reimbursement rules were being stripped daily. The first change that had major impact is when the Centers for Medicare and Medicaid Services can you buy zithromax (CMS) announced that they would temporarily begin reimbursing for virtual visits conducted in the patientâs home for buy antibiotics and non-buy antibiotics related visits. We were already frantically designing a virtual program to handle the wave of buy antibiotics screening visits that were overloading our emergency departments and urgent cares. We were having plenty of discussions around reimbursement for this clinic.

Do we attempt to bill insurances knowing they will likely deny, do we do a cash can you buy zithromax clinic model or do we do this as a community benefit and eat the cost?. The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing. Realistically we donât know if we will be paid for any of this. We are holding all of the bills for at least 90 days while the industry sorts out the can you buy zithromax rules.

I was excited by the reimbursement announcement because I knew we had eliminated one of the biggest direct-to-consumer virtual care barriers. However, I was quickly brought back to reality when I was reminded that HIPAA (Health Insurance Portability and Accountability Act) still existed. I had this crazy idea that during a zithromax we should make it as easy as possible for people to receive virtual care and that the best way to do that was to meet the patient on the device they are most comfortable with and the application (FaceTime, Facebook, Skype, etc.) that can you buy zithromax they use every day. The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because âitâs not secure.â Iâm not quite sure what a hacker stands to gain by listening into to my doctor and me talk about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry.

Sure, not every health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a ânon-secureâ app but why not let the patient decide through informed consent?. Regulators could also abandon this all-or-nothing approach and lighten regulations surrounding specific health conditions can you buy zithromax. The idea that regulations change based on medical situation is not new. For example, in my home state of Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance abuse.

Never mind that this same information is freely given over the phone by every office around the country can you buy zithromax daily without issue, but I digress. While my job is to innovate new pathways for care, our lawyerâs job is to protect the organization and he, along with IT security, rightfully shot down my consumer applications idea. A few days later I legitimately screamed out loud in joy when the Department of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications. The elimination of billing restrictions and HIPAA regulations changed can you buy zithromax what is possible for health care organizations to offer virtually.

Unfortunately both changes are listed as temporary and will likely be removed when the zithromax ends. Six days after the HIPAA changes were announced, we launched a centralized virtual clinic for any patient that wanted a direct-to-consumer video visit to be screened by a provider for buy antibiotics. It allows patients to call in without a referral and can you buy zithromax most patients are on-screen within five minutes of clicking the link we text them. They donât have to download an app, create an account or even be an established patient of our health system.

It saw over 900 patients in the first 12 days it was open. That is 900 real patients that received care from a physician or advanced practice provider without can you buy zithromax risking personal exposure and without going to an already overwhelmed ED or urgent care. To date, 70 percent of the patients seen by the virtual clinic did not meet CDC testing criteria for buy antibiotics. I donât believe we could have reached even half of these patients had the consumer application restrictions been kept.

A program like this almost certainly wouldnât exist if not for can you buy zithromax the regulations being lifted and even if it did, it would have taken six to 12 months to navigate barriers and implement in normal times. Sure, the urgency of a zithromax helps but the impact of provider, patients, regulators and payors being on the same page is what fueled this fire. During the virtual clinicâs first two weeks, my team turned its attention to getting over 300 providers across 60+ offices virtual so they could see their patients at home. Imagine being an immunocompromised cancer patient right now and being asked to can you buy zithromax leave your home and be exposed to other people in order to see your oncologist.

Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldnât be covered by insurance even if you did navigate the clunky apps that are HIPAA compliant. Do we really think the immunocompromised cancer patient feels any more comfortable every normal flu season?. Is it any more appropriate to ask them to can you buy zithromax risk exposure to the flu than it is to buy antibiotics?. And yet we deny them this access in normal times and it quite possibly will be stripped away from them when this crisis is over.

Now 300 to 400 patients per day in our health system are seen virtually by their own primary care doctor or specialist for non-buy antibiotics related visits. Not can you buy zithromax a single one of these would have been reimbursed one month ago and I am highly skeptical I would have gotten approval to use the software that connects us to the patient. Lastly, recall that prior to buy antibiotics, our system had only found 250 total patients that direct-to-consumer care was value-added and wasnât restricted by regulation or reimbursement. buy antibiotics has been a wake-up call to the whole country and health care is no exception.

It has put can you buy zithromax priorities in perspective and shined a light on what is truly value-added. For direct-to-consumer virtual care it has shown us what is possible when we get out of our own way. If a regulation has to be removed to allow for care during a crisis then we must question why it exists in the first place. HIPAA regulation cannot go back to its antiquated practices if we are truly going to shift the focus to patient wellness.

CMS and private payors must embrace value-added direct-to-consumer virtual care and allow patients the access they deserve. buy antibiotics has forced this industry forward, we cannot allow it to regress and be forgotten when this is over. Tom Wood is the director of trauma and virtual care for MidMichigan Health, a non-profit health system headquartered in Midland, Michigan, affiliated with Michigan Medicine, the health care division of the University of Michigan.

Many athletes have had their zithromax online without prescription baseball season shortened or cancelled due to buy antibiotics. This extra rest can be helpful in decreasing stress on the shoulder and elbow joints, but it can also lead to decreased strength and ROM. Overhead athletes need to keep their bodies strong, and a great way to achieve that is by performing a regular strengthening program.

With many gyms zithromax online without prescription remaining closed or limiting access during social distancing, that can be even more challenging. However, there are many exercises that can be done at home with minimal equipment needs. A great program to focus on during the off season is the Throwerâs Ten program that was developed with the overhead athlete in mind.

These exercises focus zithromax online without prescription on the muscle groups that matter most for the overhead athlete. We use our entire body to throw a ball and the stress on the shoulder to decelerate the arm is about twice our body weight. Most of this stress gets placed on the rotator cuff and scapular muscles that slow the arm down as we follow through with our throw.

Weakness in these muscles can zithromax online without prescription lead to problems with the shoulder and elbow joints. Common injuries can be Little League shoulder and elbow or strains to the ulnar collateral ligaments (Tommy John). If you have dealt with pain or injuries in the past, a comprehensive evaluation by a physical therapist (PT) who focuses on treating the overhead athlete can be extremely helpful in identifying areas of concern.

Your PT will evaluate your strength with zithromax online without prescription a dynamometer to look at any significant abnormalities between shoulders. They can also perform a video throwing analysis to look at ways to potentially reduce injury risk and improve performance. This can almost always be achieved with only a couple of visits, and the off season is a great time to start addressing areas of concern to be ready for next season or throwing during the winter.

Your PT can help you develop a customized zithromax online without prescription home exercise program based on your needs. Physical Therapist Kyle Stevenson, D.P.T., sees patients at MidMichiganâs Rehabilitation Services location in Greater Midland North-End Fitness Center. He has a special interest in sports medicine, and enjoys working with athletes of all ages.

He has completed specialized coursework and training for the throwing zithromax online without prescription athletes. New patients are welcome with a physician referral by calling (989) 832-5913. Those who would like more information about MidMichiganâs Rehabilitation Services may visit www.midmichigan.org/rehabilitation.Have you ever woken up with a sore throat and used your phone to get a virtual visit?.

The odds are itâs not available to zithromax online without prescription you, and there is a reason for that. You may be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during buy antibiotics and how health systems are offering virtual access like never before. Thereâs a reason for that, too.

For the past few weeks Iâve seen Facebook posts daily from former nursing colleagues zithromax online without prescription in metro Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with buy antibiotics. It makes me very proud to call these nurses my friends. As a former emergency department nurse, I recall the feeling of satisfaction knowing that Iâve helped someone on the worst day of their life.

One of zithromax online without prescription the best parts of being a nurse is knowing you matter to the only person in health care that truly matters. The patient. Several years ago I made the difficult decision to no longer perform bedside nursing and become a nurse administrator.

The biggest loss from my transition is the feeling that what zithromax online without prescription I do matters to the patient. buy antibiotics has forced a lot of us to rethink the role we play in health care and what the real priority should be. Things that were top priorities three months ago have been rightfully cast aside to either care for patients in a zithromax or prepare for the unknown future of, âWhen is our turn?.

Â For zithromax online without prescription me, buy antibiotics has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront of care during this crisis. It has also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently. When I became the director of virtual care at our organization in 2015 I knew nothing about telehealth.

Sure, I zithromax online without prescription had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company lets them FaceTime a doctor for free (spoiler alert. Itâs not FaceTime). I was tech-savvy from a consumer perspective and a tech novice from an IT perspective.

Nevertheless, my team and I spent the next few years learning as zithromax online without prescription we built one of the higher volume virtual care networks in the state of Michigan. We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around those barriers. But, there were two obstacles that we could not overcome.

Government regulation and insurance provider willingness to cover virtual visits zithromax online without prescription. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home. The need to social distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place created instant demand for direct-to-consumer virtual care.

In all honesty, Iâve always considered direct-to-consumer virtual care zithromax online without prescription to be the flashy, must-have holiday gift of the year that organizations are convinced will be the way of the future. If a health system wants to provide on-demand access to patients for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health systemâs logo on it. What a health system will struggle with is to find is enough patient demand to cover the high cost.

Remember my friends zithromax online without prescription from earlier that told me about the app their insurance gave them?. Nearly all of them followed that up by telling me theyâve never actually used it. I am fortunate that I work for an organization that understands this and instead focuses on how can we provide care that our patients actually want and need from the doctors they want to see.

Ironically, this fiscal year we had zithromax online without prescription a corporate top priority around direct-to-consumer virtual care. We wanted to expand what we thought were some successful pilots and perform 500 direct-to-consumer visits. This year has been one of the hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority.

With only four months left, we were only about halfway there. The biggest problem we ran into was that every great idea a physician zithromax online without prescription brought to me was instantly dead in the water because practically no insurance company would pay for it. There are (prior to buy antibiotics) a plethora of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a health care facility.

It is extremely limited what will be paid for in the patient home and most of it is so specific that the average patient isnât eligible to get any in-home virtual care. Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would zithromax online without prescription be covered if it happened in office. Add to that the massive capital and operating expenses it takes to build a virtual care network and you can see why these programs donât exist.

A month ago I was skeptical weâd have a robust direct-to-consumer program any time soon and then buy antibiotics hit. When buy antibiotics zithromax online without prescription started to spread rapidly in the United States, regulations and reimbursement rules were being stripped daily. The first change that had major impact is when the Centers for Medicare and Medicaid Services (CMS) announced that they would temporarily begin reimbursing for virtual visits conducted in the patientâs home for buy antibiotics and non-buy antibiotics related visits.

We were already frantically designing a virtual program to handle the wave of buy antibiotics screening visits that were overloading our emergency departments and urgent cares. We were having plenty of discussions around reimbursement for this clinic zithromax online without prescription. Do we attempt to bill insurances knowing they will likely deny, do we do a cash clinic model or do we do this as a community benefit and eat the cost?.

The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing. Realistically we donât know zithromax online without prescription if we will be paid for any of this. We are holding all of the bills for at least 90 days while the industry sorts out the rules.

The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because âitâs not secure.â Iâm not quite sure what a hacker stands to gain by listening into to my doctor and me talk about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry. Sure, not every zithromax online without prescription health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a ânon-secureâ app but why not let the patient decide through informed consent?. Regulators could also abandon this all-or-nothing approach and lighten regulations surrounding specific health conditions.

The idea that regulations change based on medical situation is not new. For example, in my home state of zithromax online without prescription Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance abuse. Never mind that this same information is freely given over the phone by every office around the country daily without issue, but I digress.

While my job is to innovate new pathways for care, our lawyerâs job is to protect the organization and he, along with IT security, rightfully shot down my consumer applications idea. A few days later I legitimately screamed out loud in joy when the Department zithromax online without prescription of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications. The elimination of billing restrictions and HIPAA regulations changed what is possible for health care organizations to offer virtually.

Unfortunately both changes are listed as temporary and will likely be removed when the zithromax ends. Six days after the HIPAA changes were announced, we launched a centralized virtual clinic zithromax online without prescription for any patient that wanted a direct-to-consumer video visit to be screened by a provider for buy antibiotics. It allows patients to call in without a referral and most patients are on-screen within five minutes of clicking the link we text them.

They donât have to download an app, create an account or even be an established patient of our health system. It saw over 900 patients in the zithromax online without prescription first 12 days it was open. That is 900 real patients that received care from a physician or advanced practice provider without risking personal exposure and without going to an already overwhelmed ED or urgent care.

To date, 70 percent of the patients seen by the virtual clinic did not meet CDC testing criteria for buy antibiotics. I donât believe we could have reached even zithromax online without prescription half of these patients had the consumer application restrictions been kept. A program like this almost certainly wouldnât exist if not for the regulations being lifted and even if it did, it would have taken six to 12 months to navigate barriers and implement in normal times.

Sure, the urgency of a zithromax helps but the impact of provider, patients, regulators and payors being on the same page is what fueled this fire. During the virtual clinicâs first two weeks, my team turned its attention to getting over zithromax online without prescription 300 providers across 60+ offices virtual so they could see their patients at home. Imagine being an immunocompromised cancer patient right now and being asked to leave your home and be exposed to other people in order to see your oncologist.

Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldnât be covered by insurance even if you did navigate the clunky apps that are HIPAA compliant. Do we zithromax online without prescription really think the immunocompromised cancer patient feels any more comfortable every normal flu season?. Is it any more appropriate to ask them to risk exposure to the flu than it is to buy antibiotics?.

And yet we deny them this access in normal times and it quite possibly will be stripped away from them when this crisis is over. Now 300 to 400 patients per day in our health system are zithromax online without prescription seen virtually by their own primary care doctor or specialist for non-buy antibiotics related visits. Not a single one of these would have been reimbursed one month ago and I am highly skeptical I would have gotten approval to use the software that connects us to the patient.

Lastly, recall that prior to buy antibiotics, our system had only found 250 total patients that direct-to-consumer care was value-added and wasnât restricted by regulation or reimbursement. buy antibiotics has been a zithromax online without prescription wake-up call to the whole country and health care is no exception. It has put priorities in perspective and shined a light on what is truly value-added.

For direct-to-consumer virtual care it has shown us what is possible when we get out of our own way. If a regulation has zithromax online without prescription to be removed to allow for care during a crisis then we must question why it exists in the first place. HIPAA regulation cannot go back to its antiquated practices if we are truly going to shift the focus to patient wellness.

Where can I keep Zithromax?

Keep out of the reach of children in a container that small children cannot open. Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Throw away any unused medicine after the expiration date.

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ÂBringing down air pollution to WHO guideline levels, for example, would zithromax without prescription reduce the total number of global deaths from air pollution by 80% while dramatically reducing the greenhouse gas emissions that fuel climate change. A shift to more nutritious, plant-based diets in line with WHO recommendations, as another example, could reduce global emissions significantly, ensure more resilient food systems, and avoid up to 5.1 million diet-related deaths a year by 2050.âAchieving the goals of the Paris Agreement would save millions of lives every year due to improvements in air quality, diet, and physical activity, among other benefits. However, most climate decision-making processes zithromax without prescription currently do not account for these health co-benefits and their economic valuation.

Notes to editors:WHOâs COP26 Special Report on Climate Change and Health, The Health Argument for Climate Action, provides 10 recommendations for governments on how to maximize the health benefits of tackling climate change in a variety of sectors, and avoid the worst health impacts of the climate crisis.The recommendations are the result of extensive consultations with health professionals, organizations and stakeholders worldwide, and represent a broad consensus zithromax without prescription statement from the global health community on the priority actions governments need to take to tackle the climate crisis, restore biodiversity, and protect health.Climate and Health RecommendationsThe COP26 report includes ten recommendations that highlight the urgent need and numerous opportunities for governments to prioritize health and equity in the international climate regime and sustainable development agenda.Commit to a healthy recovery. Commit to a healthy, green and just recovery from buy antibiotics.Our health is not negotiable. Place health and social zithromax without prescription justice at the heart of the UN climate talks.Harness the health benefits of climate action.

Prioritize those climate interventions with the largest health-, social- and economic zithromax without prescription gains.Build health resilience to climate risks. Build climate resilient and environmentally sustainable health systems and facilities, and support health adaptation and resilience across sectors.Create energy systems that protect and improve climate and health. Guide a just zithromax without prescription and inclusive transition to renewable energy to save lives from air pollution, particularly from coal combustion.

End energy poverty in households and health care facilities.Reimagine urban environments, transport and mobility. Promote sustainable, healthy urban design and transport systems, with improved land-use, access http://www.ec-gustave-dore-strasbourg.ac-strasbourg.fr/wp/?p=2174 to green and blue public space, and priority for walking, cycling and public transport.Protect and restore nature zithromax without prescription as the foundation of our health. Protect and restore natural systems, the foundations for healthy lives, zithromax without prescription sustainable food systems and livelihoods.Promote healthy, sustainable and resilient food systems.

Promote sustainable and resilient food production and more affordable, nutritious diets that deliver on both climate and health outcomes.Finance a healthier, fairer and greener future to save lives. Transition towards a wellbeing economy.Listen to the zithromax without prescription health community and prescribe urgent climate action. Mobilize and support the health community on climate action.Open Letter â Healthy Climate PrescriptionThe health community around the world (300 organizations representing at least 45 million doctors and health professionals) signed an open letter to national leaders and COP26 country delegations, calling for real action to address the climate crisis.The letter states the zithromax without prescription following demands:âWe call on all nations to update their national climate commitments under the Paris Agreement to commit to their fair share of limiting warming to 1.5Â°C.

And we call on them to build health into those plans;We call on all nations to deliver a rapid and just transition away from fossil fuels, starting with immediately cutting all related permits, subsidies and financing for fossil fuels, and to completely shift current financing into development of clean energy;We call on high income countries to make larger cuts to greenhouse gas emissions, in line with a 1.5Â°C temperature goal;We call on high income countries to also provide the promised transfer of funds to low-income countries to help achieve the necessary mitigation and adaptation measures;We call on governments to build climate resilient, low-carbon, sustainable health systems. AndWe call on governments to also ensure that zithromax recovery investments support climate action and reduce social and health inequities.âThe World Health Organizationâs new Mental Health Atlas paints a disappointing picture of a worldwide failure to provide people with the mental health services they need, at a time when the buy antibiotics zithromax is highlighting a growing need for mental health support.The latest edition of the Atlas, which includes data from 171 countries, provides a clear zithromax without prescription indication that the increased attention given to mental health in recent years has yet to result in a scale-up of quality mental services that is aligned with needs. Issued every three years, the Atlas is a zithromax without prescription compilation of data provided by countries around the world on mental health policies, legislation, financing, human resources, availability and utilization of services and data collection systems.

The only 2020 target met was a reduction in the rate of suicide by 10%, but even then, only 35 countries said they had a stand-alone prevention strategy, policy or plan.Steady progress was zithromax without prescription evident, however, in the adoption of mental health policies, plans and laws, as well as in improvements in capacity to report on a set of core mental health indicators. However, the percentage of government health budgets spent on mental health has scarcely changed during the zithromax without prescription last years, still hovering around 2%. Moreover, even when policies and plans included estimates of required human and financial resources, just 39% of responding countries indicated that the necessary human resources had been allocated and 34% that the required financial resources had been provided.Transfer of care to the community is slowWhile the systematic decentralization of mental health care to community settings has long been recommended by WHO, only 25% of responding countries met all the criteria for integration of mental health into primary care.

While progress has been made in training and supervision in most countries, the supply of medicines for mental health conditions and psychosocial care in primary health-care services remains limited.This is also reflected in the way that government funds to mental health are allocated, highlighting zithromax without prescription the urgent need for deinstitutionalization. More than zithromax without prescription 70% of total government expenditure on mental health was allocated to mental hospitals in middle-income countries, compared with 35% in high-income countries. This indicates that centralized mental hospitals and institutional inpatient care still receive more funds than services provided in general hospitals and primary health-care centres in many countries.

There was, however, an increase in the percentage of countries reporting that treatment of people with specific mental health conditions (psychosis, bipolar disorder and depression) is included in national health insurance or reimbursement schemes â from 73% in 2017 to 80% (or 55% of Member States) in 2020.Global estimates of people receiving care for specific mental health conditions (used as a proxy for mental health care as a whole) remained zithromax without prescription less than 50%, with a global median of 40% of people with depression and just 29% of people with psychosis receiving care.Increase in mental health promotion, but effectiveness questionableMore encouraging was the increase in countries reporting mental health promotion and prevention programmes, from 41% of Member States in 2014 to 52% in 2020. However, 31% of total reported programmes did not have dedicated human and financial resources, 27% did not have zithromax without prescription a defined plan, and 39% had no documented evidence of progress and/or impact.Slight increase in the mental health workforceThe global median number of mental health workers per 100 000 population has increased slightly from nine workers in 2014 to 13 workers per 100 000 population in 2020. However, there was a very high variation between countries of different income levels, with the number of mental health workers in high-income countries more than 40 times higher than in low-income countries.New targets for 2030The global targets reported on in the Mental Health Atlas are from WHOâs Comprehensive Mental Health Action Plan, which contained targets for 2020 endorsed by the World Health Assembly in 2013.

This Plan has zithromax without prescription now been extended to 2030 and includes new targets for the inclusion of mental health and psychosocial support in emergency preparedness plans, the integration of mental health into primary health care, and research on mental health.âThe new data from the Mental Health Atlas shows us that we still have a very long way to go in making sure that everyone, everywhere, has access to quality mental health care,â said DÃ©vora Kestel, Director of the Department of Mental Health and Substance Use at WHO. ÂBut I am encouraged by the renewed vigour that we saw from governments as the new targets for 2030 were discussed and agreed and am confident that together we can do what is necessary to move from baby steps to giant leaps forward in the next 10 years.âNote for editors:The Atlas is being released in the lead-up to World Mental Health Day on 10 October, for which the focus this year is scaling up access to quality mental health care..

Countries must set ambitious national climate commitments if they are to sustain a healthy and green recovery from the buy antibiotics zithromax.The WHO COP26 Special Report on Climate Change and Health, launched today, in the lead-up to the United Nations Climate Change Conference (COP26) in Glasgow, Scotland, zithromax online without prescription spells out the global health communityâs prescription for climate action based on a growing body of research that establishes the many and inseparable links between climate and health.âThe buy antibiotics zithromax has shone a light on the intimate and delicate links between humans, animals and our environment,â said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. ÂThe same unsustainable choices zithromax online without prescription that are killing our planet are killing people. WHO calls on all countries to commit to decisive action at COP26 to limit global warming to 1.5Â°C â not just because itâs the right thing to do, but because itâs in our own interests. WHOâs new report highlights 10 priorities for safeguarding the health of people and the planet that sustains us.âThe WHO report is launched at the same time as an open letter, signed by over two thirds of the global health workforce - 300 organizations representing at least 45 million doctors and health professionals worldwide, calling for national leaders and COP26 country delegations to step up climate action.âWherever we deliver care, in our hospitals, clinics and communities around the world, we are already responding to the health harms caused by climate change,â the letter from health professionals reads zithromax online without prescription. ÂWe call on the leaders of every country and their representatives at COP26 to avert zithromax online without prescription the impending health catastrophe by limiting global warming to 1.5Â°C, and to make human health and equity central to all climate change mitigation and adaptation actions.âThe report and open letter come as unprecedented extreme weather events and other climate impacts are taking a rising toll on peopleâs lives and health.

Increasingly frequent extreme weather events, such as heatwaves, storms and floods, kill thousands and disrupt millions of lives, while threatening healthcare systems and facilities when they are needed most. Changes in weather and climate are threatening food security and driving up food-, zithromax online without prescription water- and vector-borne diseases, such as malaria, while climate impacts are also negatively affecting mental health. The WHO report zithromax online without prescription states. ÂThe burning of fossil fuels is killing us. Climate change is zithromax online without prescription the single biggest health threat facing humanity.

While no one is safe from the health impacts of climate change, they are disproportionately felt by the most vulnerable and disadvantaged.âMeanwhile, air pollution, primarily the result of burning fossil fuels, which also drives climate change, causes 13 deaths per minute worldwide.The report concludes that protecting peopleâs health requires transformational action in every sector, including on energy, transport, nature, food systems and finance. And it states clearly that the public health benefits from implementing ambitious climate actions far zithromax online without prescription outweigh the costs.âIt has never been clearer that the climate crisis is one of the most urgent health emergencies we all face,â said Dr Maria Neira, WHO Director of Environment, Climate Change and Health. ÂBringing down air pollution to WHO guideline levels, for example, would reduce the total number of global deaths from air pollution by 80% while dramatically reducing the greenhouse gas zithromax online without prescription emissions that fuel climate change. A shift to more nutritious, plant-based diets in line with WHO recommendations, as another example, could reduce global emissions significantly, ensure more resilient food systems, and avoid up to 5.1 million diet-related deaths a year by 2050.âAchieving the goals of the Paris Agreement would save millions of lives every year due to improvements in air quality, diet, and physical activity, among other benefits. However, most climate decision-making processes currently zithromax online without prescription do not account for these health co-benefits and their economic valuation.

Notes to editors:WHOâs COP26 Special Report on Climate Change and Health, The Health Argument for Climate Action, provides 10 recommendations for governments on how to maximize the health benefits of tackling climate change in a variety of sectors, zithromax online without prescription and avoid the worst health impacts of the climate crisis.The recommendations are the result of extensive consultations with health professionals, organizations and stakeholders worldwide, and represent a broad consensus statement from the global health community on the priority actions governments need to take to tackle the climate crisis, restore biodiversity, and protect health.Climate and Health RecommendationsThe COP26 report includes ten recommendations that highlight the urgent need and numerous opportunities for governments to prioritize health and equity in the international climate regime and sustainable development agenda.Commit to a healthy recovery. Commit to a healthy, green and just recovery from buy antibiotics.Our health is not negotiable. Place health and social justice zithromax online without prescription at the heart of the UN climate talks.Harness the health benefits of climate action. Prioritize those climate interventions with the largest zithromax online without prescription health-, social- and economic gains.Build health resilience to climate risks. Build climate resilient and environmentally sustainable health systems and facilities, and support health adaptation and resilience across sectors.Create energy systems that protect and improve climate and health.

Guide a just and inclusive transition zithromax online without prescription to renewable energy to save lives from air pollution, particularly from coal combustion. End energy poverty in households and health care facilities.Reimagine urban environments, transport and mobility. Promote sustainable, healthy urban design and transport systems, with improved land-use, access to green zithromax online without prescription and blue public space, and priority for walking, cycling and public transport.Protect and restore nature as the foundation of our health. Protect and restore natural systems, the foundations for healthy zithromax online without prescription lives, sustainable food systems and livelihoods.Promote healthy, sustainable and resilient food systems. Promote sustainable and resilient food production and more affordable, nutritious diets that deliver on both climate and health outcomes.Finance a healthier, fairer and greener future to save lives.

Transition towards a wellbeing economy.Listen to the health community and prescribe zithromax online without prescription urgent climate action. Mobilize and support the health community on climate action.Open Letter â Healthy Climate PrescriptionThe health community around the world (300 organizations representing at least 45 million doctors and health professionals) signed an open letter to national leaders and COP26 country delegations, calling for real action to address the climate crisis.The letter states the following demands:âWe call on all nations to update their national climate commitments under the Paris zithromax online without prescription Agreement to commit to their fair share of limiting warming to 1.5Â°C. And we call on them to build health into those plans;We call on all nations to deliver a rapid and just transition away from fossil fuels, starting with immediately cutting all related permits, subsidies and financing for fossil fuels, and to completely shift current financing into development of clean energy;We call on high income countries to make larger cuts to greenhouse gas emissions, in line with a 1.5Â°C temperature goal;We call on high income countries to also provide the promised transfer of funds to low-income countries to help achieve the necessary mitigation and adaptation measures;We call on governments to build climate resilient, low-carbon, sustainable health systems. AndWe call on governments to also ensure that zithromax recovery investments support climate action and reduce social and health inequities.âThe World Health Organizationâs new Mental Health Atlas paints a disappointing picture of a worldwide failure to provide people with the mental health services they need, at a time when the buy antibiotics zithromax is highlighting a growing need for mental health support.The latest edition of the Atlas, which includes data zithromax online without prescription from 171 countries, provides a clear indication that the increased attention given to mental health in recent years has yet to result in a scale-up of quality mental services that is aligned with needs. Issued every three years, the Atlas zithromax online without prescription is a compilation of data provided by countries around the world on mental health policies, legislation, financing, human resources, availability and utilization of services and data collection systems.

It is also the mechanism for monitoring progress towards meeting the targets in WHOâs Comprehensive Mental Health Action Plan.âIt is extremely concerning that, despite the evident and increasing need for mental health services, which has become even more acute during the buy antibiotics zithromax, good intentions are not being met with investment,â said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. ÂWe must heed and act on this wake-up call and dramatically accelerate the scale-up of investment in mental health, because there is no health without mental health.âLack of progress in leadership, governance and financingNone of the targets for effective leadership and governance for mental health, provision of mental health services in community-based settings, mental health promotion and prevention, and strengthening of information systems, were close to being achieved.In 2020, just 51% of WHOâs 194 Member States reported that their mental health policy or plan was in line with international and regional human rights instruments, way short of the zithromax online without prescription 80% target. And only 52% of countries met the target relating to mental health promotion and prevention programmes, also well below the 80% target. The only 2020 target met was a reduction in the rate of suicide by 10%, but even then, only 35 countries said they had a stand-alone prevention strategy, policy or plan.Steady progress was evident, however, in the adoption of mental health policies, zithromax online without prescription plans and laws, as well as in improvements in capacity to report on a set of core mental health indicators. However, the percentage of government health budgets spent on zithromax online without prescription mental health has scarcely changed during the last years, still hovering around 2%.

Moreover, even when policies and plans included estimates of required human and financial resources, just 39% of responding countries indicated that the necessary human resources had been allocated and 34% that the required financial resources had been provided.Transfer of care to the community is slowWhile the systematic decentralization of mental health care to community settings has long been recommended by WHO, only 25% of responding countries met all the criteria for integration of mental health into primary care. While progress has been made in training and supervision in most countries, the supply of medicines for mental health conditions and psychosocial care in primary health-care services remains limited.This is also reflected in the way that government funds to mental health are allocated, highlighting the urgent zithromax online without prescription need for deinstitutionalization. More than 70% of total government expenditure on mental health was allocated to mental hospitals in middle-income countries, compared with 35% in high-income countries zithromax online without prescription. This indicates that centralized mental hospitals and institutional inpatient care still receive more funds than services provided in general hospitals and primary health-care centres in many countries. There was, however, an increase in the percentage of countries reporting that treatment of people with specific mental health conditions (psychosis, bipolar disorder and depression) is included in national health insurance or reimbursement schemes â from 73% in 2017 to 80% (or 55% of Member States) in 2020.Global estimates of people receiving care for specific mental health conditions (used as a proxy for mental health care as a whole) remained less than 50%, with a global median of 40% of people with depression and just 29% of people with psychosis receiving care.Increase in mental health promotion, but effectiveness questionableMore encouraging was the increase zithromax online without prescription in countries reporting mental health promotion and prevention programmes, from 41% of Member States in 2014 to 52% in 2020.

However, 31% of total reported programmes did not have dedicated human and financial resources, 27% did not have a defined plan, and 39% had no documented evidence of zithromax online without prescription progress and/or impact.Slight increase in the mental health workforceThe global median number of mental health workers per 100 000 population has increased slightly from nine workers in 2014 to 13 workers per 100 000 population in 2020. However, there was a very high variation between countries of different income levels, with the number of mental health workers in high-income countries more than 40 times higher than in low-income countries.New targets for 2030The global targets reported on in the Mental Health Atlas are from WHOâs Comprehensive Mental Health Action Plan, which contained targets for 2020 endorsed by the World Health Assembly in 2013. This Plan has now been extended to 2030 and includes new targets for the inclusion of mental health and psychosocial support in emergency preparedness plans, the integration of mental health into primary health care, and research on mental health.âThe new data from the Mental Health Atlas shows zithromax online without prescription us that we still have a very long way to go in making sure that everyone, everywhere, has access to quality mental health care,â said DÃ©vora Kestel, Director of the Department of Mental Health and Substance Use at WHO. ÂBut I am encouraged by the renewed vigour that we saw from governments as the new targets for 2030 were discussed and agreed and am confident that together we can do what is necessary to move from baby steps to giant leaps forward in the next 10 years.âNote for editors:The Atlas is being released in the lead-up to World Mental Health Day on 10 October, for which the focus this year is scaling up access to quality mental health care..

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This document zithromax online without prescription is unpublished. It is scheduled to be published on 07/07/2021. Once it is published zithromax online without prescription it will be available on this page in an official form. Until then, you can download the unpublished PDF version. Although we make a concerted effort to reproduce the original document in full on our Public Inspection pages, in some cases graphics may not be displayed, and non-substantive markup language may appear alongside substantive text.

If you are using public inspection listings for legal research, you should verify the contents of documents against a zithromax online without prescription final, official edition of the Federal Register. Only official editions of the Federal Register provide legal notice to the public and judicial notice to the courts under 44 U.S.C. 1503 & zithromax online without prescription. 1507. Learn more here..

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How to cite this article:Singh OP zithromax directions. Psychiatry research in India. Closing the zithromax directions research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science.

Research in India in general and medical research in particular is always being criticized for lack of innovation and originality zithromax directions required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which zithromax directions helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India.

According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to zithromax directions the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017â2018) of the Department of Health Research observed that âthe biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.â[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely zithromax directions due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of zithromax directions the biomedical research in India are conducted in medical institutions. The majority of these are done as thesis submission for fulfillment of the requirement of PG degree.

From 2015 onward, publication of papers had been made an obligatory requirement for zithromax directions promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore zithromax directions.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes.

Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure. They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work.

Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk â the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J.

Updated science-wide author databases of standardized citation indicators. PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim.

The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme.

Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords.

India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population.

The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015â2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs â one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%â25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large âtreatment gap.â[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research. Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature.

Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. ÂMental health,â âMental disorders,â âMental illness,â âPsychiatry,â âScheduled Tribeâ OR âTribeâ OR âTribal Populationâ OR âIndigenous population,â âIndia,â âPsych*â (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail.

Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality. The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified.

Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment.

It was observed that wages were used to buy opium. In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a âchoiceâ than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together.

Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%â4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders.

Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers.

Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners.

There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment. Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care.

Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by âquack doctorsâ and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available.

All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles. Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively.

The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple âtalk therapy.â Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health â Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 â have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder.

Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization. Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to zithromax online without prescription cite this article:Singh OP http://controlmyproject.com/?p=1. Psychiatry research in India. Closing the research zithromax online without prescription gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science.

Research in India in general and medical research in particular is zithromax online without prescription always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose zithromax online without prescription it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India.

According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to the Indian population owing to differences in zithromax online without prescription biology, health-care systems, health practices, culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017â2018) of the Department of Health Research observed that âthe biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.â[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National zithromax online without prescription Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of zithromax online without prescription the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions. The majority of these are done as thesis submission for fulfillment of the requirement of PG degree.

From 2015 onward, publication zithromax online without prescription of papers had been made an obligatory requirement for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore zithromax online without prescription.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J.

Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

References 1.Gururaj G, Girish N, Isaac MK. Mental. Neurological and Substance abuse disorders. Strategies towards a systems approach.

In. Burden of Disease in India. Equitable development â Healthy future New Delhi, India. National Commission on Macroeconomics and Health.

Ministry of Health and Family Welfare, Government of India. 2005. 2.Math SB, Srinivasaraju R. Indian Psychiatric epidemiological studies these details.