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Medsphere Systems has acquired Micro-Office Systems in a move designed to enhance the value and usability of Medsphere’s health IT solutions and services.WHY IT MATTERSWith more than 30 years of health IT experience, Micro-Office Systems focuses on creating the in-between technology that streamlines the functionality of various platforms and applications ventolin price comparison to the benefit of administrators, clinicians and patients. HIMSS20 Digital Learn on-demand, earn credit, find products ventolin price comparison and solutions. Get Started >>. Its product portfolio includes numerous interfaces to improve communication and integration ventolin price comparison among solutions.

System migration tools and strategies to smooth and hasten the transition from one system to another. And the ventolin price comparison Patient Communications Gateway, a comprehensive, modular system that empowers healthcare organizations to effectively communicate with patients.Medsphere said the breadth of its solution and service portfolio makes clear the value of solutions like those Micro-Office Systems provides. Medsphere’s electronic health records systems serve acute and psychiatric inpatient settings, ambulatory environments, and emergency rooms.The company’s revenue cycle management ventolin price comparison suite is designed to improve financial performance in all healthcare settings. And the Phoenix Health consulting and outsourcing division provides services many hospitals need but have trouble obtaining, Medsphere contended.THE LARGER TRENDThe acquisition of Micro-Office Systems is Medsphere’s most recent move to expand company offerings.

In recent years, Medsphere has grown steadily, through acquisitions such as ambulatory health IT solutions provider ChartLogic, health IT consulting and outsourcing provider Phoenix Health Systems, revenue cycle management systems developer Stockell Healthcare, and the Wellsoft emergency department information system.Moving forward, ventolin price comparison Micro-Office Systems will retain its name with the added modifier, “A Division of Medsphere.”ON THE RECORD“The entire healthcare IT industry, with as many products as there are, has evolved to the point where the connective tissue is just about as important as the muscle and bone,” said Medsphere president and CEO Irv Lichtenwald in a statement. €œEven when healthcare IT was in its relative infancy, Micro-Office Systems was improving communication among platforms and making localized systems work better for all users.”“The reality is that some wealthy hospitals and health systems can afford to purchase a mostly complete platform from one vendor, but that’s not necessarily the best acquisition approach, and it certainly isn’t available to all healthcare organizations,” added Micro-Office Systems CEO Norman Efroymson. €œWe believe Medsphere’s approach ventolin price comparison of effectively linking robust technology to create a platform all providers can afford will win the day, which is why we’re on board.”Twitter. @SiwickiHealthITEmail the ventolin price comparison writer.

Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication.The Sequoia Project and the Blue Cross Blue Shield Association say new research shows promise for expanding an existing person matching framework to payers – boosting the prospects for more seamless interoperability as patient identification efforts gain steam in policy circles and at provider organizations.WHY IT MATTERSThe new study, "Person Matching for Greater Interoperability. A Case Study for Payers," shows extremely high matching accuracy rates, the groups say, and offers perspectives that can help boost patient identification efforts across the health plans – a must-have for more expansive health information exchange and interoperability.The Sequoia ventolin price comparison Project worked with BCBSA to apply its Framework for Cross-Organizational Patient Identity Management – first developed with Intermountain Healthcare, back in 2016 – to the payer community, expanding opportunities for more accurate person matching. HIMSS20 Digital Learn on-demand, earn credit, find products and solutions ventolin price comparison. Get Started >>.

The cross-organizational framework's first iteration detailed how provider-to-provider matching and exchange could be optimized, describing best practices and offering a maturity model to point the way toward more widespread improvements in nationwide patient matching.Since its publication, a Patient Identity Framework Work Group was convened, and the stakeholder feedback led to a revised version two years ago that has since served as a guide for many providers and HIEs nationwide.The new case study, meant as a supplement to that, homes in on payers, and the case study it offers – an algorithm enabling a 99.5% matching accuracy rate across 36 different organizations – suggests big potential for other healthcare stakeholders going forward."Since our provider-focused framework was published in 2016 and revised in 2018, we've seen tremendous interest in ventolin price comparison how we apply those principles to raise the floor for interoperability," said Sequoia Project CEO Mariann Yeager in a statement."When the Blue Cross Blue Shield Association agreed to collaborate on the application of these principles to the unique needs of the payer community, we were thrilled for the opportunity to work together to expand our thinking from 'patient matching among providers' to 'person matching in other settings.'"THE LARGER TRENDPatient matching and identification efforts have gained some momentum in recent months, after being a major hindrance to interoperability for years.In July, the U.S. House of Representatives voted to overturn a long-standing hurdle to developing a unique patient identifier – approving the Foster-Kelly Amendment, which removes language that prohibits federal funding for research into a unique patient ID.And so groups such as the Patient ID Now coalition are lobbying policymakers in Washington to push for a national strategy to address patient identification.When it comes to interoperability, "there are just too many fundamental gaps," said Hal Wolf, CEO of HIMSS (parent company of Healthcare IT News), a member of Patient ID Now. "We've done a great job, the United States, ventolin price comparison of developing components of HIE. But there's an underlying dependency that we're missing, you know, and that's the individual patient identifier."The asthma treatment ventolin has put a harsh spotlight on the need for better patient matching, as Congressional leaders were reminded this spring by the Pew Charitable Trusts."Congress should work with federal agencies – such as the Office of the National Coordinator for Health Information Technology and the U.S.

Postal Service – to ensure that they are using all the available tools they ventolin price comparison have so that public health entities can effectively trace contacts and track immunizations," said Ben Moscovitch, Pew's project director for health information technology.He pointed to the fact that phone numbers aren't often exchanged between labs and public health authorities who could do contact tracing. In many cases, even if they are, the numbers are for ordering physicians, not patients."As a result, contact tracers spend indispensable time searching for a phone number or email address to contact an individual," he said, "all while the ventolin may be spreading by unknowingly infected individuals that have not been reached via contact tracing mechanisms."ON THE RECORD"The ability to match someone with their health data – regardless if they've changed insurers – is critical to ensuring people receive the care they need and deserve," said Rich Cullen, vice president at BCBSA in a statement."To address this health industry need, we developed a way to safely and securely match a person's health data from one Blue Cross and ventolin price comparison Blue Shield company to another. We believe this will lay the foundation for larger health data-sharing efforts within the broader health care system. We thank The Sequoia Project for their expertise and collaborative leadership, which is critical now as we ventolin price comparison continue to advance industry standards to make meaningful health information easily accessible." Twitter.

@MikeMiliardHITNEmail the writer. Mike.miliard@himssmedia.comHealthcare IT News is a HIMSS publication.The asthma treatment crisis has spurred all kinds of technical innovation, not ventolin price comparison just virtual visits. For United Methodist Communities in Neptune, New Jersey, the ventolin gave them the opportunity, and the necessity, to launch a remote monitoring program, starting with fall detection, that has led to an 80% reduction in falls.On today's episode host Jonah Comstock ventolin price comparison welcomes Larry Carlson, CEO of UMC, to look back at that experience and look ahead to the future of remote patient monitoring at UMC.This podcast is brought to you by Kajeet. HIMSS20 Digital Learn on-demand, earn credit, find products and solutions.

Get Started ventolin price comparison >>. More about this podcast:United Methodist Communities has early successes with telehealth and RPMA guide to connected health device and remote patient monitoring vendorsHospitals get additional $20 billion infusion of CARES Act fundsHow fall detection is moving beyond the pendant.

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(1) While therapies ought to provide patients with sufficient information to make informed treatment decisions, informed consent does not require that practitioners ‘go open’ about therapeutic common factors in psychotherapy, and (2) clarity about the mechanisms of change in psychotherapy shows us that the common-factors findings are consistent with, rather than undermining of, the truth of many theory-specific forms of psychotherapy. Psychotherapy, as it is commonly practiced, is not deceptive and is not a placebo. The call to ‘go open’ should be resisted and may have serious detrimental effects on patients via the dissemination of a false view about how therapy works.psychotherapyinformed consentpaternalismethics.

This ‘deception’ claim is based on the findings that some, and possibly most, of the ameliorative Cheap cipro canada effects in psychotherapeutic interventions are mediated by therapeutic common factors shared by successful treatments (eg, expectancy effects and therapist ventolin price comparison effects), rather than because of theory-specific techniques. These findings have led to claims that psychotherapy is, at least partly, likely a placebo, and that practitioners of psychotherapy have a duty to ‘go open’ to patients about the role of common factors in therapy (even if this risks negatively affecting the efficacy of treatment). To not ‘go open’ is supposed to unjustly restrict patients’ autonomy.

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The call to ‘go open’ should be resisted and may have serious detrimental effects on patients via the dissemination of a false view about how therapy works.psychotherapyinformed consentpaternalismethics.

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NSW Health is providing a $1 million boost to a new redirected here cancer best place to buy ventolin online and wellness centre in Echuca to help deliver chemotherapy and dialysis to cross-border communities.The Echuca Cancer and Wellness Centre will be part of Echuca Regional Health, which services about 44,000 people in Murray River Council and the shires of Hay, Deniliquin, Moama, Balranald in NSW, and Campaspe Shire in Victoria. Health Minister Brad Hazzard said the NSW Government invests millions of dollars in services and infrastructure across the state to ensure regional communities can access the best health care possible.“Echuca, on the Victorian side of the border, and Moama, on the NSW best place to buy ventolin online side, are in a similar situation to Albury-Wodonga. These border towns identify as single communities, with residents crossing the border daily to access services,” Mr Hazzard said.“This new centre will provide patients in cross-border communities with world-class, critical cancer services and treatments right on their doorstep.”Echuca Regional Health Chief Executive Nick Bush thanked the NSW Government for its $1 million commitment. €œWe appreciate the support of the NSW Government of the Echuca-Moama best place to buy ventolin online and surrounding community.

It is very exciting to see the project progressing. The purpose-built facility will best place to buy ventolin online give patients the best care in a wonderful, new centre in our community.”NSW and Victoria have a long-standing agreement for cross-border health care. In 2020/2021, NSW will reimburse about $63 million to Victoria, on top of the $120 million NSW Health provides to Albury-Wodonga Health for NSW residents.Planning is underway for the centre, which will provide access to haematologists, medical oncologists, nephrologists and radiation oncologists for more than 1,200 patients each year. Murrumbidgee Local best place to buy ventolin online Health District provides a cancer diagnosis service at Deniliquin Hospital, and there are plans to recruit and train staff in oncology.​Concord Hospital’s $341 million redevelopment is on track for completion, with the eight-storey Clinical Services Building set to transform healthcare in the inner west.Health Minister Brad Hazzard and Member for Drummoyne John Sidoti visited the site for a traditional topping out ceremony to mark the building reaching its highest point.

Mr Hazzard said the Clinical Services Building will have more than 200 inpatient beds, with just over 550 beds across the campus, an increase of more than 100 from previously. €œThe NSW Government’s $341 million commitment to Concord Hospital has created more than 700 construction jobs to build this best place to buy ventolin online modern, state-of-the-art facility,” Mr Hazzard said. €œNot only does it house the nation’s first dedicated veterans’ health service, a comprehensive cancer centre and an aged care centre, over two-thirds of the new inpatient beds in the new Clinical Services Building are in single rooms with daybeds for carers.” Mr Sidoti said the National Centre for Veterans’ Healthcare has been successfully operating as a pilot service since August last year. To date 128 people have been referred to the service and 54 have best place to buy ventolin online completed their care.

€œThis Centre is critical to our veteran community and continues Concord Hospital’s proud 80-year history of supporting veterans and their families,” Mr Sidoti said. Concord Hospital’s new Clinical Services best place to buy ventolin online Building will include. the Rusty Priest Centre for Rehabilitation and Aged CareNational Centre for Veterans’ Healthcare a comprehensive Cancer Care Centre with 28 beds and 48 chemotherapy, infusion and haematology chairsa new concourse linking the new building to the existing hospital, providing direct access to operating theatres, radiology and emergency care.Construction of a new $32.4 million multistorey car park will begin following the completion of the Clinical Services Building expected in late 2021. The NSW best place to buy ventolin online Government also spent $1.3 million in 2019 refurbishing two theatres at Concord Hospital that are now fully digitally integrated.

NSW Health is providing a $1 million boost to a new cancer and wellness centre in Echuca to help deliver chemotherapy and dialysis to cross-border communities.The Echuca Cancer and Wellness Centre https://wolf-garten.nl/buy-kamagra-100mg-generic-viagra will be part of Echuca Regional Health, which services about 44,000 people ventolin price comparison in Murray River Council and the shires of Hay, Deniliquin, Moama, Balranald in NSW, and Campaspe Shire in Victoria. Health Minister Brad Hazzard said the ventolin price comparison NSW Government invests millions of dollars in services and infrastructure across the state to ensure regional communities can access the best health care possible.“Echuca, on the Victorian side of the border, and Moama, on the NSW side, are in a similar situation to Albury-Wodonga. These border towns identify as single communities, with residents crossing the border daily to access services,” Mr Hazzard said.“This new centre will provide patients in cross-border communities with world-class, critical cancer services and treatments right on their doorstep.”Echuca Regional Health Chief Executive Nick Bush thanked the NSW Government for its $1 million commitment. €œWe appreciate the support of the NSW Government of ventolin price comparison the Echuca-Moama and surrounding community. It is very exciting to see the project progressing.

The purpose-built facility will give patients the best care in a wonderful, new centre in our ventolin price comparison community.”NSW and Victoria have a long-standing agreement for cross-border health care. In 2020/2021, NSW will reimburse about $63 million to Victoria, on top of the $120 million NSW Health provides to Albury-Wodonga Health for NSW residents.Planning is underway for the centre, which will provide access to haematologists, medical oncologists, nephrologists and radiation oncologists for more than 1,200 patients each year. Murrumbidgee Local Health District provides a cancer diagnosis service at Deniliquin Hospital, and there are plans to recruit and train staff in oncology.​Concord Hospital’s $341 million redevelopment is on track for completion, with the eight-storey Clinical Services Building set to transform healthcare in the inner west.Health Minister Brad Hazzard and Member for Drummoyne John Sidoti visited the site for a traditional ventolin price comparison topping out ceremony to mark the building reaching its highest point. Mr Hazzard said the Clinical Services Building will have more than 200 inpatient beds, with just over 550 beds across the campus, an increase of more than 100 from previously. €œThe NSW Government’s $341 million commitment to ventolin price comparison Concord Hospital has created more than 700 construction jobs to build this modern, state-of-the-art facility,” Mr Hazzard said.

€œNot only does it house the nation’s first dedicated veterans’ health service, a comprehensive cancer centre and an aged care centre, over two-thirds of the new inpatient beds in the new Clinical Services Building are in single rooms with daybeds for carers.” Mr Sidoti said the National Centre for Veterans’ Healthcare has been successfully operating as a pilot service since August last year. To date ventolin price comparison 128 people have been referred to the service and 54 have completed their care. €œThis Centre is critical to our veteran community and continues Concord Hospital’s proud 80-year history of supporting veterans and their families,” Mr Sidoti said. Concord Hospital’s new Clinical Services Building ventolin price comparison will include. the Rusty Priest Centre for Rehabilitation and Aged CareNational Centre for Veterans’ Healthcare a comprehensive Cancer Care Centre with 28 beds and 48 chemotherapy, infusion and haematology chairsa new concourse linking the new building to the existing hospital, providing direct access to operating theatres, radiology and emergency care.Construction of a new $32.4 million multistorey car park will begin following the completion of the Clinical Services Building expected in late 2021.

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Shutterstock Researchers looking at combining two medications to treat how can i buy ventolin methamphetamine disorder think their approach may be a safe and effective way to treat click this site addicted adults. By combining injectable naltrexone and oral bupropion, researchers within the National Institute on Drug Abuse Clinical Trials Network, part of the National Institutes of Health, have seen success in treating patients with moderate to severe methamphetamine use disorder in addition to other approaches to treatment, such as cognitive behavioral therapy and contingency management interventions. €œThe opioid crisis and resulting overdose deaths in the United States are now well known, but what is less recognized is that there is a growing crisis of how can i buy ventolin overdose deaths involving methamphetamine and other stimulants.

However, unlike for opioids, there are currently no approved medications for treating methamphetamine use disorder,” said NIDA Director Nora D. Volkow. €œThis advance demonstrates that medical treatment for methamphetamine use disorder can help improve patient outcomes.”The study, “Accelerated Development of how can i buy ventolin Additive Pharmacotherapy Treatment for Methamphetamine Use Disorder,” was conducted between 2017 and 2019 at clinics across the country.

Using 403 adult volunteers between 18 and 65 with moderate to severe methamphetamine use disorder, the study provided some volunteers with the naltrexone, bupropion combination while giving the other placebos. Urine samples were collected throughout the study, and a volunteer was considered successfully treated if three of four urine samples came back without traces of methamphetamine. The study found that participants taking the drug combination were more likely to report that they had fewer cravings for the drug how can i buy ventolin and greater improvements in their lives.

Additionally, there were no significant adverse effects associated with the drug combination. €œLong-term methamphetamine misuse has been shown to cause diffuse changes to the brain, which can contribute to severe health consequences beyond addiction itself,” said Dr. Madhukar H how can i buy ventolin.

Trivedi of the University of Texas Southwestern Medical Center, Dallas, who led the trial. €œThe good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”.

Shutterstock Researchers looking at combining two medications ventolin price comparison to treat methamphetamine disorder think their approach may be a safe and effective way to treat addicted adults. By combining injectable naltrexone and oral bupropion, researchers within the National Institute on Drug Abuse Clinical Trials Network, part of the National Institutes of Health, have seen success in treating patients with moderate to severe methamphetamine use disorder in addition to other approaches to treatment, such as cognitive behavioral therapy and contingency management interventions. €œThe opioid crisis and resulting overdose deaths in the United States are now well known, but what is less recognized is that there is a growing crisis of overdose deaths ventolin price comparison involving methamphetamine and other stimulants. However, unlike for opioids, there are currently no approved medications for treating methamphetamine use disorder,” said NIDA Director Nora D.

Volkow. €œThis advance demonstrates that medical treatment for methamphetamine use disorder can help improve patient outcomes.”The study, “Accelerated Development of Additive Pharmacotherapy ventolin price comparison Treatment for Methamphetamine Use Disorder,” was conducted between 2017 and 2019 at clinics across the country. Using 403 adult volunteers between 18 and 65 with moderate to severe methamphetamine use disorder, the study provided some volunteers with the naltrexone, bupropion combination while giving the other placebos. Urine samples were collected throughout the study, and a volunteer was considered successfully treated if three of four urine samples came back without traces of methamphetamine.

The study found that ventolin price comparison participants taking the drug combination were more likely to report that they had fewer cravings for the drug and greater improvements in their lives. Additionally, there were no significant adverse effects associated with the drug combination. €œLong-term methamphetamine misuse has been shown to cause diffuse changes to the brain, which can contribute to severe health consequences beyond addiction itself,” said Dr. Madhukar H ventolin price comparison.

Trivedi of the University of Texas Southwestern Medical Center, Dallas, who led the trial. €œThe good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”.

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A man wearing a face mask as a preventive measures against asthma treatment walks along an empty street in Chinatown.Wong Fok Loy| SOPA Images | what is ventolin hfa LightRocket via Getty ImagesThe asthma treatment outbreak in Malaysia has become one of the worst globally.On a seven-day moving average basis, Malaysia recorded 483.72 confirmed asthma treatment s per million people on Wednesday — the eighth highest globally and top in Asia, according to the latest data compiled by online repository Our World in Data.Meanwhile, the country's daily reported deaths relating to asthma treatment were around 4.90 per million people on Tuesday on a seven-day moving average basis. That's the 19th highest globally and third highest in Asia, the data showed.Our World in Data is a collaboration between researchers at the University of Oxford and U.K. Non-profit organization Global Change Data Lab.Malaysia managed what is ventolin hfa to keep the number of s low for much of 2020.

But the country has struggled to tame a surge in cases despite implementing multiple rounds of restrictions and a state of emergency.Political analysts blame the government's mishandling of the outbreak as it worsened."Malaysia's response is being hampered by chaotic governance and persistent political infighting," Joshua Kurlantzick, senior fellow for Southeast Asia at think tank Council on Foreign Relations, wrote in a report.Malaysia's political crisisThe Southeast Asian country plunged into political turmoil when former Prime Minister Mahathir Mohamad unexpectedly resigned in February last year. It paved the way for Muhyiddin to form a government by cobbling together a fragile coalition.Political opponents have long challenged what is ventolin hfa Muhyiddin's claim of majority support in the country's 222-seat parliament. Calls for the prime minister's resignation — even among his allies — grew louder after Malaysia's king on Thursday issued a rare rebuke over the government's handling of the state of emergency.The king had consented to Muhyiddin's request for a state of emergency from January to August 1 to manage the country's surging asthma treatment s.Many analysts considered the move an attempt by the embattled prime minister to preserve his political standing, especially when parliament was suspended under the emergency and elections cannot be held.When parliament reconvened this week, the government surprised the nation by announcing that it had decided to end the emergency effective July 21.

The king said the government's unilateral revocation did what is ventolin hfa not follow constitutional procedure.Since coming to power, Muhyiddin has sought to avoid parliamentary votes that his political opponents could use as a proxy to a no-confidence vote against his leadership. The Malaysian parliament has never voted on a no-confidence motion.asthma treatment vaccinations picking upDespite the political tussle, Malaysian authorities have accelerated the pace of vaccinations in recent weeks. More than 18% of the country's 32 million population what is ventolin hfa have been fully vaccinated, according to Our World in Data.

Economists from British bank Barclays estimated that Malaysia — along with Singapore and South Korea — will be among the Asian countries to reach "critical levels" of vaccinations this year.CNBC Health &. Science The Malaysian government said it aimed what is ventolin hfa to inoculate most of the adult population by year-end.Still, economists said the worsening outbreak and ongoing social-distancing measures have hurt Malaysia's growth outlook.Barclays last month cut its 2021 growth projection from 5.5% to 5%. That's well below the Malaysian central bank's forecast range of 6% to 7.5%.Professional sports leagues are uniquely positioned to track breakthrough asthma treatment cases because they test thousands of athletes consistently, according to Dr.

Robby Sikka, a physician who has worked with numerous NBA and NFL teams.Sikka told CNBC that the what is ventolin hfa highly transmissible delta variant is "absolutely" driving most of the asthma treatment breakthrough cases he's studied."Delta is driving this," said Sikka, the founder of Sports Medicine Analytics Research Team, an organization that assists numerous professional sports leagues with injury data."We know that the delta variant has a higher viral load, it's more infectious, it's more contagious, and it is driving cases in the community. There's an extremely high viral burden in the community."As asthma treatment cases surge nationwide, new research is showing that fully vaccinated people can transmit the ventolin as asymptomatic carriers. More than 5,900 fully vaccinated Americans have either died or been hospitalized with what is ventolin hfa asthma treatment breakthrough s through July 19, according to the Centers for Disease Control and Prevention's most recent data.

The website also notes that 1,821 of those cases were either "asymptomatic or not related to asthma treatment."Sikka told "The News with Shepard Smith" that treatments do work to prevent severe illness when it comes to asthma treatment and the delta variant, and that a key takeaway from sports is that vaccinated athletes come back sooner than those who are unvaccinated. "The athletes that have gotten asthma treatment, despite being vaccinated, by and large, returned what is ventolin hfa and have done well and been able to return and perform at a high level," said Sikka.The eighth meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (2005) (IHR) regarding the asthma disease (asthma treatment) took place on Wednesday, 14 July 2021 from 11:30 to 16:00 Geneva time (CEST). Proceedings of the meetingMembers and Advisors of the Emergency Committee were convened by videoconference.

The Director-General welcomed the Committee and reiterated his global call for action to scale up vaccination and implement rationale use of public health and social what is ventolin hfa measures (PHSM). He thanked the Committee for their continued support in identifying key challenges and solutions that countries can use to overcome the issues posed by the ventolin. Representatives of the Office of Legal Counsel (LEG) what is ventolin hfa and the Department of Compliance, Risk Management, and Ethics (CRE) briefed the members on their roles and responsibilities.

The Ethics Officer from CRE provided the Members and Advisers with an overview of the WHO Declaration of Interest process. The Members and Advisers were made aware of their what is ventolin hfa individual responsibility to disclose to WHO, in a timely manner, any interests of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or direct conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and the work of the Committee.

Each member who was present was surveyed and no conflicts of interest what is ventolin hfa were identified. The Secretariat turned the meeting over to the Chair, Professor Didier Houssin. Professor Houssin also expressed what is ventolin hfa concern over the current trends with the asthma treatment ventolin and reviewed the objectives and agenda of the meeting.

The Secretariat presented on the global epidemiological context, shared updates on travel guidance and measures taken by countries and provided an overview of the World Health Assembly 74’s decisions and resolutions that relate to the role and functioning of the IHR Emergency Committee. The Secretariat also highlighted factors driving the current situation including:variants of concern, inconsistent application of public health and social measures, increased social mobility, and what is ventolin hfa highly susceptible populations due to lack of equitable treatment distribution. The Committee discussed key themes including.

Global inequitable access to asthma treatments which is compounded by use what is ventolin hfa of the available treatments beyond SAGE recommended priority populations and the administration of booster doses while many countries do not have sufficient access to initial doses;the need for technology transfer to enhance global vaccination production capacity,the importance of adapting PHSM to epidemiological and socio-economic contexts and to diverse types of gatherings, challenges posed by the lack of harmonization in documentation requirements for vaccination and recovery status for international travel, threats posed by current and future SARS CoV-2 variants of concern, andefforts made by some States Parties to apply a risk-management approach to religious or sports-based mass gathering events. The ventolin remains a challenge globally with countries navigating different health, economic and social demands. The Committee noted that regional and economic differences are what is ventolin hfa affecting access to treatments, therapeutics, and diagnostics.

Countries with advanced access to treatments and well-resourced health systems are under pressure to fully reopen their societies and relax the PHSM. Countries with limited access to treatments what is ventolin hfa are experiencing new waves of s, seeing erosion of public trust and growing resistance to PHSM, growing economic hardship, and, in some instances, increasing social unrest. As a result, governments are making increasingly divergent policy decisions that address narrow national needs which inhibit a harmonized approach to the global response.

In this regard, the Committee was highly concerned about the inadequate funding of WHO’s Strategic Preparedness and Response Plan and called for more flexible and predictable funding to support WHO’s what is ventolin hfa leadership role in the global ventolin response.The Committee noted that, despite national, regional, and global efforts, the ventolin is nowhere near finished. The ventolin continues to evolve with four variants of concern dominating global epidemiology. The Committee recognised the strong what is ventolin hfa likelihood for the emergence and global spread of new and possibly more dangerous variants of concern that may be even more challenging to control.

The Committee expressed appreciation for States Parties engaging in research to increase understanding of asthma treatments and requested that clinical trial volunteers not be disadvantaged in travel arrangements due to their participation in research studies. At the same time, the risk of emergence of new what is ventolin hfa zoonotic diseases while still responding to the current ventolin has been emphasised by the Committee. The Committee noted the importance of States Parties’ continued vigilance for detection and mitigation of new zoonotic diseases.The Committee unanimously agreed that the asthma treatment ventolin still constitutes an extraordinary event that continues to adversely affect the health of populations around the world, poses a risk of international spread and interference with international traffic, and requires a coordinated international response.

As such, the what is ventolin hfa Committee concurred that the asthma treatment ventolin remains a public health emergency of international concern (PHEIC) and offered the following advice to the Director-General. The Director-General determined that the asthma treatment ventolin continues to constitute a PHEIC. He accepted the what is ventolin hfa advice of the Committee to WHO and issued the Committee’s advice to States Parties as Temporary Recommendations under the IHR.

The Emergency Committee will be reconvened within three months or earlier, at the discretion of the Director-General. The Director-General thanked the Committee for its work.Advice to the WHO SecretariatContinue to work with States Parties to implement PHSM to control transmission, taking into account the acceptability, feasibility, costs, effects, and the balance between benefits what is ventolin hfa and harms in each epidemiological and socio-economic context. Continue to advocate for equitable treatment access and distribution by encouraging sharing of available treatment doses, expanded local production capacity in low- and middle-income countries, waiving intellectual property rights, leveraging technology transfer, scale up of manufacturing, and calling for the necessary global funding.

Update and disseminate guidance related what is ventolin hfa to appropriate use of treatments (including topics such as booster doses and heterologous use of treatments). Expedite the work to establish updated means for documenting asthma treatment status of travelers, including vaccination, history of asthma , and asthma test results. This includes both an interim what is ventolin hfa update to the WHO booklet containing the International Certificate of Vaccination and Prophylaxis and digital solutions which allow for verification of relevant information.

Continue to strengthen the global monitoring and assessment framework for SARS CoV-2 variants and provide updated guidance to support States Parties in establishing, leveraging, and expanding genomic sequencing capacities as well as timely sharing of information, data, and samples. Strengthen communication strategies at national, regional and global levels to reduce asthma treatment transmission and counter misinformation, including rumours that fuel treatment hesitancy what is ventolin hfa. This will require reinforcing messages that a comprehensive public health response continues to be needed, including the continued use of PHSM regardless of vaccination coverage.

Collect information from States Parties on their uptake what is ventolin hfa and progress made in implementing the Temporary Recommendations. Temporary Recommendations to States PartiesWhile the Committee noted that there are nuances associated with diverse regional contexts related to the implementation of the Temporary Recommendations, they identified the following as critical for all countries. Continue to use evidence-informed PHSM based on real what is ventolin hfa time monitoring of the epidemiologic situation and health system capacities, taking into account the potential cumulative effects of these measures.

The use of masks, physical distancing, hand hygiene, and improved ventilation of indoor spaces remains key to reducing transmission of SARS CoV-2. The use of established public health measures in response to individual cases or clusters of cases, including contact tracing, quarantine and isolation, must continue to be adapted to the epidemiological and social context and enforced. Link to WHO guidanceImplement a risk-management approach for mass gathering events by evaluating, mitigating, and what is ventolin hfa communicating risks.

Recognizing that there are different drivers and risk tolerance for mass gatherings, it is critical to consider the epidemiological context (including the prevalence of variants of concern, the strength of transmission, as well as contract tracing and testing capacity) when conducting this risk assessment in line with WHO guidance. Link to what is ventolin hfa WHO guidance. Achieve the WHO call to action to have at least 10% of all countries’ populations vaccinated by September 2021.

Increased global what is ventolin hfa solidarity is needed to protect vulnerable populations from the emergence and spread of SARS CoV-2 variants. Noting that many countries have now vaccinated their priority populations, it is recommended that doses should be shared with countries that have limited access before expanding national vaccination programmes into lower risk groups. Vaccination programmes what is ventolin hfa should include vulnerable populations, including sea farers and air crews.

Link to WHO guidance.Enhance surveillance of asthma and continue to report to WHO to enable rapid identification, tracking, and evaluation of variants and continued monitoring of the ventolin’s evolution. To achieve this recommendation, States Parties may need to strengthen their epidemiological what is ventolin hfa and virologic (including genomic) surveillance and reporting systems or share samples with countries that have this capacity. Link to WHO guidance.Improve access to and safe administration of WHO recommended therapeutics, including oxygen, to treat asthma treatment.

In addition, it is important for States Parties to conduct clinical research on and support access to care for patients suffering from what is ventolin hfa post asthma treatment condition (also known as long asthma treatment). States Parties should also continue research on therapeutics for the prevention of asthma treatment s where feasible. Link to WHO resource.Continue a risk-based approach to facilitate international travel and share information with WHO on use of travel measures what is ventolin hfa and their public health rationale.

In accordance with the IHR, measures (e.g. Masking, testing, isolation/quarantine, and vaccination) should be based on risk assessments, consider local circumstances, and avoid placing the financial burden on international travellers what is ventolin hfa in accordance with Article 40 of the IHR. Link to WHO guidance.

Do NOT require proof of vaccination against asthma treatment for international travel as the only pathway or condition permitting international what is ventolin hfa travel, given limited global access and inequitable distribution of asthma treatments. Link to WHO interim position paper. State Parties should consider a risk-based approach to the facilitation of international travel by lifting measures, such as testing and/or quarantine requirements, when appropriate, in what is ventolin hfa accordance with the WHO guidance.

Link to WHO guidance. Recognize all asthma treatments that have received WHO Emergency Use Listing in the context of international what is ventolin hfa travel. In addition, States Parties are encouraged to include information on asthma treatment status, in accordance with WHO guidance, within the WHO booklet containing the International Certificate of Vaccination and Prophylaxis.

And to use the digitized what is ventolin hfa version when available. Address community engagement and communications gaps at national and local levels to reduce asthma treatment transmission, counter misinformation, and improve asthma treatment acceptance, where applicable. This will require reinforcing messages that a comprehensive public health response is needed, including the continued use of what is ventolin hfa PHSM alongside increasing vaccination coverage.

Link to WHO risk communications resources.23 million children missed out on basic treatments through routine immunization services in 2020 – 3.7 million more than in 2019 - according to official data published today by WHO and UNICEF. This latest set of comprehensive worldwide childhood immunization figures, the first official figures to reflect global service disruptions due to asthma treatment, show a majority of countries last year experienced drops in childhood vaccination rates.Concerningly, most of these – up to 17 million children – likely did not receive what is ventolin hfa a single treatment during the year, widening already immense inequities in treatment access. Most of these children live in communities affected by conflict, in under-served remote places, or in informal or slum settings where they face multiple deprivations including limited access to basic health and key social services.“Even as countries clamour to get their hands on asthma treatments, we have gone backwards on other vaccinations, leaving children at risk from devastating but preventable diseases like measles, polio or meningitis,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

€œMultiple disease outbreaks would be catastrophic for communities and health systems already battling asthma treatment, making it more urgent than ever to invest in childhood vaccination and ensure every child what is ventolin hfa is reached.”In all regions, rising numbers of children miss vital first treatment doses in 2020. Millions more miss later treatmentsDisruptions in immunization services were widespread in 2020, with the WHO Southeast Asian and Eastern Mediterranean Regions most affected. As access to health services and immunization outreach were curtailed, the what is ventolin hfa number of children not receiving even their very first vaccinations increased in all regions.

As compared with 2019, 3.5 million more children missed their first dose of diphtheria, tetanus and pertussis treatment (DTP-1) while 3 million more children missed their first measles dose. €œThis evidence should be a clear warning – the asthma treatment ventolin and related disruptions cost us valuable ground we cannot afford to lose – and the consequences will be paid in the lives and wellbeing of the most vulnerable,” said what is ventolin hfa Henrietta Fore, UNICEF Executive Director. €œEven before the ventolin, there were worrying signs that we were beginning to lose ground in the fight to immunize children against preventable child illness, including with the widespread measles outbreaks two years ago.

The ventolin what is ventolin hfa has made a bad situation worse. With the equitable distribution of asthma treatments at the forefront of everyone’s minds, we must remember that treatment distribution has always been inequitable, but it does not have to be.”Table 1. Countries with the greatest increase in children not receiving a first dose of diphtheria-tetanus-pertussis combined treatment (DTP-1) 20192020India1'403'0003'038'000Pakistan567'000968'000Indonesia472'000797'000Philippines450'000557'000Mexico348000454'000Mozambique97'000186'000Angola399'000482'000United Republic of Tanzania183'000249'000Argentina97'000156'000Venezuela (Bolivarian Republic of)75'000134'000Mali136'000193'000The data shows that middle-income countries now account what is ventolin hfa for an increasing share of unprotected children – that is, children missing out on at least some treatment doses.

India is experiencing a particularly large drop, with DTP-3 coverage falling from 91% to 85%.Fuelled by funding shortfalls, treatment misinformation, instability and other factors, a troubling picture is also emerging in WHO’s Region of the Americas, where vaccination coverage continues to fall. Just 82% of children are fully vaccinated with DTP, down from 91% in 2016.Countries risk resurgence of measles, other treatment-preventable diseasesEven what is ventolin hfa prior to the asthma treatment ventolin, global childhood vaccination rates against diphtheria, tetanus, pertussis, measles and polio had stalled for several years at around 86%. This rate is well below the 95% recommended by WHO to protect against measles –often the first disease to resurge when children are not reached with treatments - and insufficient to stop other treatment-preventable diseases.With many resources and personnel diverted to support the asthma treatment response, there have been significant disruptions to immunization service provision in many parts of the world.

In some countries, clinics have been closed or hours reduced, while people may have been reluctant to seek healthcare because of fear of what is ventolin hfa transmission or have experienced challenges reaching services due to lockdown measures and transportation disruptions.“These are alarming numbers, suggesting the ventolin is unravelling years of progress in routine immunization and exposing millions of children to deadly, preventable diseases”, said Dr Seth Berkley, CEO of Gavi, the treatment Alliance. €œThis is a wake-up call – we cannot allow a legacy of asthma treatment to be the resurgence of measles, polio and other killers. We all need to work together to help countries both defeat asthma treatment, by ensuring global, equitable access to treatments, and get routine immunization programmes back on track what is ventolin hfa.

The future health and wellbeing of millions of children and their communities across the globe depends on it.” Concerns are not just for outbreak-prone diseases. Already at low rates, vaccinations against human papillomaventolin (HPV) - which protect girls against cervical what is ventolin hfa cancer later in life - have been highly affected by school closures. As a result, across countries that have introduced HPV treatment to date, approximately 1.6 million more girls missed out in 2020.

Globally only 13% girls were vaccinated against HPV, falling from 15% in 2019.Agencies call for urgent recovery and investment in routine immunizationAs countries work to recover lost ground due to asthma treatment related disruptions, UNICEF, WHO and partners like Gavi, the treatment Alliance are supporting efforts to strengthen immunization systems by:Restoring services and vaccination campaigns so countries can safely deliver routine immunization programmes during the asthma treatment ventolin;Helping health workers and community leaders communicate actively with caregivers to explain what is ventolin hfa the importance of vaccinations;Rectifying gaps in immunization coverage, including identifying communities and people who have been missed during the ventolin.Ensuring that asthma treatment delivery is independently planned for and financed and that it occurs alongside, and not at the cost of childhood vaccination services.Implementing country plans to prevent and respond to outbreaks of treatment-preventable diseases, and strengthen immunization systems as part of asthma treatment recovery effortsThe agencies are working with countries and partners to deliver the ambitious targets of the global Immunization Agenda 2030, which aims to achieve 90% coverage for essential childhood treatments. Halve the number of entirely unvaccinated, or ‘zero dose’ children, and increase the uptake of newer lifesaving treatments such as rotaventolin or pneumococcus in low and middle-income countries.###Notes for editorsAccess the full data set here (from 15th July 2021). Https://www.who.int/data/immunizationMultimedia.

Https://who.canto.global/b/PLVSO https://weshare.unicef.org/Package/2AMZIFH25X95treatments For All campaign page. Https://www.unicef.org/treatmentsAbout the dataBased on country-reported data, the official WHO and UNICEF estimates of national immunization coverage (WUENIC) provide the world’s largest data-set on immunization trends for vaccinations against 13 diseases given through regular health systems - normally at clinics or community centres or health worker visits. For 2020, data was provided from 160 countries.Globally, the vaccination rate for three doses of diphtheria-tetanus and pertussis (DTP-3) treatment fell from around 86% in 2019 to 83% in 2020, meaning 22.7 million children missed out, and for measles first dose, from 86 to 84%, meaning 22.3 million children missed out.

Vaccination rates for measles second dose were at 71% (from 70% in 2019). To control measles, 95% uptake of two treatment doses is required. Countries that cannot reach that level rely on periodic nationwide vaccination campaigns to fill the gap.

In addition to routine immunization disruptions, there are currently 57 postponed mass vaccination campaigns in 66 countries, for measles, polio, yellow fever and other diseases, affecting millions more people.New modelling also shows significant declines in DTP, measles vaccination coverageNew modelling, also published today in The Lancet by researchers at the Washington-based Institute for Health Metrics and Evaluation (IHME), similarly shows that childhood vaccination declined globally in 2020 due to asthma treatment disruptions. The IHME-led modelling is based on country-reported administrative data for DTP and measles treatments, supplemented by reports on electronic medical records and human movement data captured through anonymized tracking of mobile phones.Both analyses show that countries and the broader health community must ensure that new waves of asthma treatment and the massive roll out of asthma treatment 19 treatments don’t derail routine immunization and that catch-up activities continue to be enhanced..

A man wearing a face mask as a preventive measures against asthma treatment walks along an empty street in Chinatown.Wong Fok Loy| SOPA Images | LightRocket via Getty ImagesThe asthma treatment outbreak in Malaysia has become one of ventolin price comparison the worst globally.On a seven-day moving average basis, Malaysia recorded 483.72 confirmed asthma treatment s per million people on Wednesday — the eighth highest globally and top in Asia, according to the latest data compiled by online repository Our World in Data.Meanwhile, the country's daily reported deaths relating to asthma treatment were around 4.90 per million people on Tuesday on a seven-day moving average basis. That's the 19th highest globally and third highest in Asia, the data showed.Our World in Data is a collaboration between researchers at the University of Oxford and U.K. Non-profit organization Global ventolin price comparison Change Data Lab.Malaysia managed to keep the number of s low for much of 2020.

But the country has struggled to tame a surge in cases despite implementing multiple rounds of restrictions and a state of emergency.Political analysts blame the government's mishandling of the outbreak as it worsened."Malaysia's response is being hampered by chaotic governance and persistent political infighting," Joshua Kurlantzick, senior fellow for Southeast Asia at think tank Council on Foreign Relations, wrote in a report.Malaysia's political crisisThe Southeast Asian country plunged into political turmoil when former Prime Minister Mahathir Mohamad unexpectedly resigned in February last year. It paved the way for Muhyiddin to form a government by cobbling together a ventolin price comparison fragile coalition.Political opponents have long challenged Muhyiddin's claim of majority support in the country's 222-seat parliament. Calls for the prime minister's resignation — even among his allies — grew louder after Malaysia's king on Thursday issued a rare rebuke over the government's handling of the state of emergency.The king had consented to Muhyiddin's request for a state of emergency from January to August 1 to manage the country's surging asthma treatment s.Many analysts considered the move an attempt by the embattled prime minister to preserve his political standing, especially when parliament was suspended under the emergency and elections cannot be held.When parliament reconvened this week, the government surprised the nation by announcing that it had decided to end the emergency effective July 21.

The king said the government's unilateral revocation did not follow constitutional procedure.Since coming to power, Muhyiddin has sought to avoid parliamentary votes that his political opponents could use as a proxy ventolin price comparison to a no-confidence vote against his leadership. The Malaysian parliament has never voted on a no-confidence motion.asthma treatment vaccinations picking upDespite the political tussle, Malaysian authorities have accelerated the pace of vaccinations in recent weeks. More than 18% of the country's 32 million population have been fully vaccinated, according to Our World ventolin price comparison in Data.

Economists from British bank Barclays estimated that Malaysia — along with Singapore and South Korea — will be among the Asian countries to reach "critical levels" of vaccinations this year.CNBC Health &. Science The Malaysian government said it aimed to inoculate most of the adult population by year-end.Still, economists said the worsening outbreak and ongoing social-distancing measures have hurt Malaysia's growth outlook.Barclays last month cut its 2021 growth projection from 5.5% to 5% ventolin price comparison. That's well below the Malaysian central bank's forecast range of 6% to 7.5%.Professional sports leagues are uniquely positioned to track breakthrough asthma treatment cases because they test thousands of athletes consistently, according to Dr.

Robby Sikka, a physician who has worked with numerous NBA and NFL teams.Sikka told CNBC that the highly transmissible delta variant is "absolutely" driving most of the asthma treatment breakthrough cases he's studied."Delta is driving this," said Sikka, the founder of Sports Medicine Analytics Research Team, an organization that assists numerous professional sports leagues with injury data."We know ventolin price comparison that the delta variant has a higher viral load, it's more infectious, it's more contagious, and it is driving cases in the community. There's an extremely high viral burden in the community."As asthma treatment cases surge nationwide, new research is showing that fully vaccinated people can transmit the ventolin as asymptomatic carriers. More than 5,900 fully vaccinated Americans have either died or ventolin price comparison been hospitalized with asthma treatment breakthrough s through July 19, according to the Centers for Disease Control and Prevention's most recent data.

The website also notes that 1,821 of those cases were either "asymptomatic or not related to asthma treatment."Sikka told "The News with Shepard Smith" that treatments do work to prevent severe illness when it comes to asthma treatment and the delta variant, and that a key takeaway from sports is that vaccinated athletes come back sooner than those who are unvaccinated. "The athletes that have gotten asthma treatment, despite being vaccinated, by and large, returned and have done well and been able to return ventolin price comparison and perform at a high level," said Sikka.The eighth meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (2005) (IHR) regarding the asthma disease (asthma treatment) took place on Wednesday, 14 July 2021 from 11:30 to 16:00 Geneva time (CEST). Proceedings of the meetingMembers and Advisors of the Emergency Committee were convened by videoconference.

The Director-General welcomed the Committee and ventolin price comparison reiterated his global call for action to scale up vaccination and implement rationale use of public health and social measures (PHSM). He thanked the Committee for their continued support in identifying key challenges and solutions that countries can use to overcome the issues posed by the ventolin. Representatives of the Office of Legal Counsel (LEG) and the Department ventolin price comparison of Compliance, Risk Management, and Ethics (CRE) briefed the members on their roles and responsibilities.

The Ethics Officer from CRE provided the Members and Advisers with an overview of the WHO Declaration of Interest process. The Members and Advisers were made aware of their individual responsibility to disclose to WHO, in a timely manner, any interests of a personal, professional, financial, intellectual or commercial nature that ventolin price comparison may give rise to a perceived or direct conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and the work of the Committee.

Each member who was present was surveyed ventolin price comparison and no conflicts of interest were identified. The Secretariat turned the meeting over to the Chair, Professor Didier Houssin. Professor Houssin also expressed concern over the current trends with the asthma treatment ventolin and ventolin price comparison reviewed the objectives and agenda of the meeting.

The Secretariat presented on the global epidemiological context, shared updates on travel guidance and measures taken by countries and provided an overview of the World Health Assembly 74’s decisions and resolutions that relate to the role and functioning of the IHR Emergency Committee. The Secretariat also highlighted factors driving the current situation including:variants of concern, inconsistent application of public health and social measures, increased social mobility, and highly susceptible ventolin price comparison populations due to lack of equitable treatment distribution. The Committee discussed key themes including.

Global inequitable access to asthma treatments which is compounded by use of the available treatments beyond SAGE recommended priority populations and the administration of booster doses while many countries do not have sufficient access to initial doses;the need for technology transfer to enhance global vaccination production capacity,the importance of adapting PHSM to epidemiological and socio-economic contexts and to diverse types of gatherings, challenges posed by the lack of harmonization in documentation requirements for vaccination and recovery status for international travel, threats posed by current and future SARS CoV-2 variants of concern, andefforts made by some States Parties to apply a risk-management approach to ventolin price comparison religious or sports-based mass gathering events. The ventolin remains a challenge globally with countries navigating different health, economic and social demands. The Committee noted that regional and economic differences are affecting access to treatments, therapeutics, and ventolin price comparison diagnostics.

Countries with advanced access to treatments and well-resourced health systems are under pressure to fully reopen their societies and relax the PHSM. Countries with limited access to treatments are experiencing new waves of s, seeing erosion of public trust and growing resistance to PHSM, growing economic hardship, and, in some instances, increasing social unrest ventolin price comparison. As a result, governments are making increasingly divergent policy decisions that address narrow national needs which inhibit a harmonized approach to the global response.

In this regard, the Committee was highly concerned about the inadequate funding of WHO’s Strategic Preparedness and Response Plan and called for more flexible and predictable funding to support WHO’s leadership role in the global ventolin response.The Committee noted that, despite national, regional, and global ventolin price comparison efforts, the ventolin is nowhere near finished. The ventolin continues to evolve with four variants of concern dominating global epidemiology. The Committee recognised the strong likelihood for the emergence and global spread of new and possibly more dangerous variants of concern that may be even more challenging to ventolin price comparison control.

The Committee expressed appreciation for States Parties engaging in research to increase understanding of asthma treatments and requested that clinical trial volunteers not be disadvantaged in travel arrangements due to their participation in research studies. At the same time, the risk of ventolin price comparison emergence of new zoonotic diseases while still responding to the current ventolin has been emphasised by the Committee. The Committee noted the importance of States Parties’ continued vigilance for detection and mitigation of new zoonotic diseases.The Committee unanimously agreed that the asthma treatment ventolin still constitutes an extraordinary event that continues to adversely affect the health of populations around the world, poses a risk of international spread and interference with international traffic, and requires a coordinated international response.

As such, ventolin price comparison the Committee concurred that the asthma treatment ventolin remains a public health emergency of international concern (PHEIC) and offered the following advice to the Director-General. The Director-General determined that the asthma treatment ventolin continues to constitute a PHEIC. He accepted the advice of the Committee to WHO and issued ventolin price comparison the Committee’s advice to States Parties as Temporary Recommendations under the IHR.

The Emergency Committee will be reconvened within three months or earlier, at the discretion of the Director-General. The Director-General thanked the Committee for its work.Advice to the WHO SecretariatContinue to work with States Parties to implement PHSM to control transmission, taking into account the acceptability, feasibility, costs, effects, and the balance between benefits and harms in each ventolin price comparison epidemiological and socio-economic context. Continue to advocate for equitable treatment access and distribution by encouraging sharing of available treatment doses, expanded local production capacity in low- and middle-income countries, waiving intellectual property rights, leveraging technology transfer, scale up of manufacturing, and calling for the necessary global funding.

Update and disseminate guidance related to appropriate use of treatments (including topics such as booster ventolin price comparison doses and heterologous use of treatments). Expedite the work to establish updated means for documenting asthma treatment status of travelers, including vaccination, history of asthma , and asthma test results. This includes both an interim update to the WHO ventolin price comparison booklet containing the International Certificate of Vaccination and Prophylaxis and digital solutions which allow for verification of relevant information.

Continue to strengthen the global monitoring and assessment framework for SARS CoV-2 variants and provide updated guidance to support States Parties in establishing, leveraging, and expanding genomic sequencing capacities as well as timely sharing of information, data, and samples. Strengthen communication strategies at national, regional and global levels to reduce asthma treatment transmission and ventolin price comparison counter misinformation, including rumours that fuel treatment hesitancy. This will require reinforcing messages that a comprehensive public health response continues to be needed, including the continued use of PHSM regardless of vaccination coverage.

Collect information from States Parties on their uptake and progress made in implementing the Temporary ventolin price comparison Recommendations. Temporary Recommendations to States PartiesWhile the Committee noted that there are nuances associated with diverse regional contexts related to the implementation of the Temporary Recommendations, they identified the following as critical for all countries. Continue to use evidence-informed PHSM based on real time monitoring of the epidemiologic situation and health ventolin price comparison system capacities, taking into account the potential cumulative effects of these measures.

The use of masks, physical distancing, hand hygiene, and improved ventilation of indoor spaces remains key to reducing transmission of SARS CoV-2. The use of established public health measures in response to individual cases or clusters of cases, including contact tracing, quarantine and isolation, must continue to be adapted to the epidemiological and social context and enforced. Link to ventolin price comparison WHO guidanceImplement a risk-management approach for mass gathering events by evaluating, mitigating, and communicating risks.

Recognizing that there are different drivers and risk tolerance for mass gatherings, it is critical to consider the epidemiological context (including the prevalence of variants of concern, the strength of transmission, as well as contract tracing and testing capacity) when conducting this risk assessment in line with WHO guidance. Link to WHO ventolin price comparison guidance. Achieve the WHO call to action to have at least 10% of all countries’ populations vaccinated by September 2021.

Increased global solidarity is needed to protect vulnerable populations from the emergence and spread of ventolin price comparison SARS CoV-2 variants. Noting that many countries have now vaccinated their priority populations, it is recommended that doses should be shared with countries that have limited access before expanding national vaccination programmes into lower risk groups. Vaccination programmes should include vulnerable populations, including sea farers and air crews ventolin price comparison.

Link to WHO guidance.Enhance surveillance of asthma and continue to report to WHO to enable rapid identification, tracking, and evaluation of variants and continued monitoring of the ventolin’s evolution. To achieve this recommendation, States Parties may need to ventolin price comparison strengthen their epidemiological and virologic (including genomic) surveillance and reporting systems or share samples with countries that have this capacity. Link to WHO guidance.Improve access to and safe administration of WHO recommended therapeutics, including oxygen, to treat asthma treatment.

In addition, it is important for States Parties to conduct clinical research on and support access to care for patients suffering from ventolin price comparison post asthma treatment condition (also known as long asthma treatment). States Parties should also continue research on therapeutics for the prevention of asthma treatment s where feasible. Link to WHO resource.Continue a risk-based approach to facilitate international travel and share information with WHO on use of travel measures and ventolin price comparison their public health rationale.

In accordance with the IHR, measures (e.g. Masking, testing, isolation/quarantine, and vaccination) should be based on risk assessments, consider local circumstances, and avoid ventolin price comparison placing the financial burden on international travellers in accordance with Article 40 of the IHR. Link to WHO guidance.

Do NOT require proof of vaccination against asthma treatment for international travel as the only pathway or condition permitting international travel, ventolin price comparison given limited global access and inequitable distribution of asthma treatments. Link to WHO interim position paper. State Parties should consider a risk-based approach to the facilitation of international travel by lifting measures, such as testing and/or quarantine requirements, when appropriate, in accordance with ventolin price comparison the WHO guidance.

Link to WHO guidance. Recognize all asthma treatments that have received WHO Emergency ventolin price comparison Use Listing in the context of international travel. In addition, States Parties are encouraged to include information on asthma treatment status, in accordance with WHO guidance, within the WHO booklet containing the International Certificate of Vaccination and Prophylaxis.

And to use the digitized ventolin price comparison version when available. Address community engagement and communications gaps at national and local levels to reduce asthma treatment transmission, counter misinformation, and improve asthma treatment acceptance, where applicable. This will require reinforcing messages that a comprehensive public health response is needed, including the continued use of ventolin price comparison PHSM alongside increasing vaccination coverage.

Link to WHO risk communications resources.23 million children missed out on basic treatments through routine immunization services in 2020 – 3.7 million more than in 2019 - according to official data published today by WHO and UNICEF. This latest set of comprehensive worldwide childhood immunization figures, the first official figures to reflect global service disruptions due to asthma treatment, show a ventolin price comparison majority of countries last year experienced drops in childhood vaccination rates.Concerningly, most of these – up to 17 million children – likely did not receive a single treatment during the year, widening already immense inequities in treatment access. Most of these children live in communities affected by conflict, in under-served remote places, or in informal or slum settings where they face multiple deprivations including limited access to basic health and key social services.“Even as countries clamour to get their hands on asthma treatments, we have gone backwards on other vaccinations, leaving children at risk from devastating but preventable diseases like measles, polio or meningitis,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

€œMultiple disease outbreaks would be catastrophic for communities and health systems already battling asthma treatment, making it more urgent than ever to invest in childhood vaccination and ventolin price comparison ensure every child is reached.”In all regions, rising numbers of children miss vital first treatment doses in 2020. Millions more miss later treatmentsDisruptions in immunization services were widespread in 2020, with the WHO Southeast Asian and Eastern Mediterranean Regions most affected. As access to health services and immunization outreach were curtailed, the number of children not receiving even their ventolin price comparison very first vaccinations increased in all regions.

As compared with 2019, 3.5 million more children missed their first dose of diphtheria, tetanus and pertussis treatment (DTP-1) while 3 million more children missed their first measles dose. €œThis evidence should be a clear warning – the asthma treatment ventolin and related disruptions cost us valuable ground we cannot afford to lose – and the consequences will be paid in the lives ventolin price comparison and wellbeing of the most vulnerable,” said Henrietta Fore, UNICEF Executive Director. €œEven before the ventolin, there were worrying signs that we were beginning to lose ground in the fight to immunize children against preventable child illness, including with the widespread measles outbreaks two years ago.

The ventolin has ventolin price comparison made a bad situation worse. With the equitable distribution of asthma treatments at the forefront of everyone’s minds, we must remember that treatment distribution has always been inequitable, but it does not have to be.”Table 1. Countries with the greatest increase in children not receiving a first dose of diphtheria-tetanus-pertussis combined treatment (DTP-1) 20192020India1'403'0003'038'000Pakistan567'000968'000Indonesia472'000797'000Philippines450'000557'000Mexico348000454'000Mozambique97'000186'000Angola399'000482'000United Republic of Tanzania183'000249'000Argentina97'000156'000Venezuela (Bolivarian Republic of)75'000134'000Mali136'000193'000The data shows that middle-income countries now account for an increasing share of unprotected children – that is, children missing out on at least some ventolin price comparison treatment doses.

India is experiencing a particularly large drop, with DTP-3 coverage falling from 91% to 85%.Fuelled by funding shortfalls, treatment misinformation, instability and other factors, a troubling picture is also emerging in WHO’s Region of the Americas, where vaccination coverage continues to fall. Just 82% of children are fully vaccinated with DTP, down from 91% in 2016.Countries risk resurgence of measles, other treatment-preventable diseasesEven prior to the asthma treatment ventolin, global childhood vaccination rates against diphtheria, tetanus, pertussis, ventolin price comparison measles and polio had stalled for several years at around 86%. This rate is well below the 95% recommended by WHO to protect against measles –often the first disease to resurge when children are not reached with treatments - and insufficient to stop other treatment-preventable diseases.With many resources and personnel diverted to support the asthma treatment response, there have been significant disruptions to immunization service provision in many parts of the world.

In some countries, clinics have been closed or hours ventolin price comparison reduced, while people may have been reluctant to seek healthcare because of fear of transmission or have experienced challenges reaching services due to lockdown measures and transportation disruptions.“These are alarming numbers, suggesting the ventolin is unravelling years of progress in routine immunization and exposing millions of children to deadly, preventable diseases”, said Dr Seth Berkley, CEO of Gavi, the treatment Alliance. €œThis is a wake-up call – we cannot allow a legacy of asthma treatment to be the resurgence of measles, polio and other killers. We all need to work together to help countries both defeat asthma treatment, by ensuring global, ventolin price comparison equitable access to treatments, and get routine immunization programmes back on track.

The future health and wellbeing of millions of children and their communities across the globe depends on it.” Concerns are not just for outbreak-prone diseases. Already at low rates, vaccinations against ventolin price comparison human papillomaventolin (HPV) - which protect girls against cervical cancer later in life - have been highly affected by school closures. As a result, across countries that have introduced HPV treatment to date, approximately 1.6 million more girls missed out in 2020.

Globally only 13% girls were vaccinated against HPV, falling from 15% in 2019.Agencies call for urgent recovery and ventolin price comparison investment in routine immunizationAs countries work to recover lost ground due to asthma treatment related disruptions, UNICEF, WHO and partners like Gavi, the treatment Alliance are supporting efforts to strengthen immunization systems by:Restoring services and vaccination campaigns so countries can safely deliver routine immunization programmes during the asthma treatment ventolin;Helping health workers and community leaders communicate actively with caregivers to explain the importance of vaccinations;Rectifying gaps in immunization coverage, including identifying communities and people who have been missed during the ventolin.Ensuring that asthma treatment delivery is independently planned for and financed and that it occurs alongside, and not at the cost of childhood vaccination services.Implementing country plans to prevent and respond to outbreaks of treatment-preventable diseases, and strengthen immunization systems as part of asthma treatment recovery effortsThe agencies are working with countries and partners to deliver the ambitious targets of the global Immunization Agenda 2030, which aims to achieve 90% coverage for essential childhood treatments. Halve the number of entirely unvaccinated, or ‘zero dose’ children, and increase the uptake of newer lifesaving treatments such as rotaventolin or pneumococcus in low and middle-income countries.###Notes for editorsAccess the full data set here (from 15th July 2021). Https://www.who.int/data/immunizationMultimedia.

Https://who.canto.global/b/PLVSO https://weshare.unicef.org/Package/2AMZIFH25X95treatments For All campaign page. Https://www.unicef.org/treatmentsAbout the dataBased on country-reported data, the official WHO and UNICEF estimates of national immunization coverage (WUENIC) provide the world’s largest data-set on immunization trends for vaccinations against 13 diseases given through regular health systems - normally at clinics or community centres or health worker visits. For 2020, data was provided from 160 countries.Globally, the vaccination rate for three doses of diphtheria-tetanus and pertussis (DTP-3) treatment fell from around 86% in 2019 to 83% in 2020, meaning 22.7 million children missed out, and for measles first dose, from 86 to 84%, meaning 22.3 million children missed out.

Vaccination rates for measles second dose were at 71% (from 70% in 2019). To control measles, 95% uptake of two treatment doses is required. Countries that cannot reach that level rely on periodic nationwide vaccination campaigns to fill the gap.

In addition to routine immunization disruptions, there are currently 57 postponed mass vaccination campaigns in 66 countries, for measles, polio, yellow fever and other diseases, affecting millions more people.New modelling also shows significant declines in DTP, measles vaccination coverageNew modelling, also published today in The Lancet by researchers at the Washington-based Institute for Health Metrics and Evaluation (IHME), similarly shows that childhood vaccination declined globally in 2020 due to asthma treatment disruptions. The IHME-led modelling is based on country-reported administrative data for DTP and measles treatments, supplemented by reports on electronic medical records and human movement data captured through anonymized tracking of mobile phones.Both analyses show that countries and the broader health community must ensure that new waves of asthma treatment and the massive roll out of asthma treatment 19 treatments don’t derail routine immunization and that catch-up activities continue to be enhanced..

How much does ventolin cost

How to how much does ventolin cost cite this article:Singh OP. The National Commission for Allied and Healthcare Professions Act, 2020 and its implication for mental health. Indian J Psychiatry 2021;63:119-20The National Commission for Allied and Healthcare Professions Act, 2020 has been notified on March 28, 2021, by the Gazette how much does ventolin cost of India published by the Ministry of Law and Justice.

This bill aims to “provide for regulation and maintenance of standards of education and services by allied and healthcare professionals, assessment of institutions, maintenance of a Central Register and State Register and creation of a system to improve access, research and development and adoption of latest scientific advancement and for matters connected therewith or incidental thereto.”[1]This act has created a category of Health Care Professionals which is defined as. €œhealthcare professional” includes a scientist, therapist, or other professional who studies, advises, researches, supervises or provides preventive, curative, rehabilitative, therapeutic or promotional health services and who has obtained any qualification of degree under this Act, the duration of which shall not be <3600 h spread over a period of 3 years to 6 years divided into specific semesters.[1]According to the act, “Allied health professional” includes an associate, technician, or technologist who is trained to perform any technical and practical task to support diagnosis and treatment of illness, disease, injury or impairment, and to support implementation of any healthcare treatment and referral plan recommended by a medical, nursing, or any other healthcare professional, and who has obtained any qualification of diploma or how much does ventolin cost degree under this Act, the duration of which shall not be less than 2000 h spread over a period of 2 years to 4 years divided into specific semesters.”[1]It is noticeable that while the term “Health Care Professionals” does not include doctors who are registered under National Medical Council, Mental Health Care Act (MHCA), 2017 includes psychiatrists under the ambit of Mental Health Care Professionals.[2] This discrepancy needs to be corrected - psychiasts, being another group of medical specialists, should be kept out of the broad umbrella of “Mental Healthcare Professionals.”The category of Behavioural Health Sciences Professional has been included and defined as “a person who undertakes scientific study of the emotions, behaviours and biology relating to a person's mental well-being, their ability to function in everyday life and their concept of self. €œBehavioural health” is the preferred term to “mental health” and includes professionals such as counselors, analysts, psychologists, educators and support workers, who provide counseling, therapy, and mediation services to individuals, families, groups, and communities in response to social and personal difficulties.”[1]This is a welcome step to the extent that it creates a diverse category of trained workforce in the field of Mental Health (Behavioural Health Science Professionals) and tries to regulate their training although it mainly aims to promote mental wellbeing.

However there is a huge lacuna in the term how much does ventolin cost of “Mental Illness” as defined by MHCA, 2017. Only severe disorders are included as per definition and there is no clarity regarding inclusion of other psychiatric disorders, namely “common mental disorders” such as anxiety and depression. This leaves a strong possibility of concept of “psychiatric illnesses” being limited to how much does ventolin cost only “severe psychiatric disorders” (major psychoses) thus perpetuating the stigma and alienation associated with psychiatric patients for centuries.

Psychiatrists being restricted to treating severe mental disorders as per MHCA, 2017, there is a strong possibility that the care of common mental disorders may gradually pass on under the care of “behavioural health professionals” as per the new act!. There is need to look into this aspect by the leadership in psychiatry, both organizational and academic psychiatry, and reduce the contradictions between the MHCA, 2017 and how much does ventolin cost this nascent act. All disorders classified in ICD 10 and DSM 5 should be classified as “Psychiatric Disorders” or “Mental Illness.” This will not only help in fighting the stigma associated with psychiatric illnesses but also promote the integration of psychiatry with other specialties.

References 1.The National Commission for Allied how much does ventolin cost and Healthcare Professions Act, 2021. The Gazette of India. Published by Ministry of Law how much does ventolin cost and Justice.

28 March, 2021. 2.The how much does ventolin cost Mental Healthcare Act, 2017. The Gazette of India.

Published by how much does ventolin cost Ministry of Law and Justice. April 7, 2017. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 how much does ventolin cost 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_268_21Abstract Thiamine is essential for the activity of several enzymes associated with energy metabolism in how much does ventolin cost humans.

Chronic alcohol use is associated with deficiency of thiamine along with other vitamins through several mechanisms. Several neuropsychiatric syndromes have been associated with thiamine deficiency in the context of alcohol use disorder including Wernicke–Korsakoff syndrome, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, how much does ventolin cost and possibly, Marchiafava–Bignami syndrome. High-dose thiamine replacement is suggested for these neuropsychiatric syndromes.Keywords.

Alcohol use disorder, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, how much does ventolin cost Marchiafava–Bignami syndrome, thiamine, Wernicke–Korsakoff syndromeHow to cite this article:Praharaj SK, Munoli RN, Shenoy S, Udupa ST, Thomas LS. High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry 2021;63:121-6How to how much does ventolin cost cite this URL:Praharaj SK, Munoli RN, Shenoy S, Udupa ST, Thomas LS.

High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry [serial online] 2021 [cited how much does ventolin cost 2021 May 20];63:121-6. Available from.

Https://www.indianjpsychiatry.org/text.asp?. 2021/63/2/121/313716 Introduction Thiamine is a water-soluble vitamin (B1) that plays a key role in the activity of several enzymes associated with energy metabolism. Thiamine pyrophosphate (or diphosphate) is the active form that acts as a cofactor for enzymes.

The daily dietary requirement of thiamine in adults is 1–2 mg and is dependent on carbohydrate intake.[1],[2] The requirement increases if basal metabolic rate is higher, for example, during alcohol withdrawal state. Dietary sources include pork (being the major source), meat, legume, vegetables, and enriched foods. The body can store between 30 and 50 mg of thiamine and is likely to get depleted within 4–6 weeks if the diet is deficient.[2] In those with alcohol-related liver damage, the ability to store thiamine is gradually reduced.[1],[2]Lower thiamine levels are found in 30%–80% of chronic alcohol users.[3] Thiamine deficiency occurs due to poor intake of vitamin-rich foods, impaired intestinal absorption, decreased storage capacity of liver, damage to the renal epithelial cells due to alcohol, leading to increased loss from the kidneys, and excessive loss associated with medical conditions.[2],[3] Furthermore, alcohol decreases the absorption of colonic bacterial thiamine, reduces the enzymatic activity of thiamine pyrophosphokinase, and thereby, reducing the amount of available thiamine pyrophosphate.[4] Since facilitated diffusion of thiamine into cells is dependent on a concentration gradient, reduced thiamine pyrophosphokinase activity further reduces thiamine uptake into cells.[4] Impaired utilization of thiamine is seen in certain conditions (e.g., hypomagnesemia) which are common in alcohol use disorder.[2],[3],[4] This narrative review discusses the neuropsychiatric syndromes associated with thiamine deficiency in the context of alcohol use disorder, and the treatment regimens advocated for these conditions.

A PubMed search supplemented with manual search was used to identify neuropsychiatric syndromes related to thiamine deficiency in alcohol use disorder patients. Neuropsychiatric Syndromes Associated With Thiamine Deficiency Wernicke–Korsakoff syndromeWernicke encephalopathy is associated with chronic alcohol use, and if not identified and treated early, could lead to permanent brain damage characterized by an amnestic syndrome known as Korsakoff syndrome. Inappropriate treatment of Wernicke encephalopathy with lower doses of thiamine can lead to high mortality rates (~20%) and Korsakoff syndrome in ~ 80% of patients (ranges from 56% to 84%).[5],[6] The classic triad of Wernicke includes oculomotor abnormalities, cerebellar dysfunction, and confusion.

Wernicke lesions are found in 12.5% of brain samples of patients with alcohol dependence.[7] However, only 20%–30% of them had a clinical diagnosis of Wernicke encephalopathy antemortem. It has been found that many patients develop Wernicke–Korsakoff syndrome (WKS) following repeated subclinical episodes of thiamine deficiency.[7] In an autopsy report of 97 chronic alcohol users, only16% had all the three “classical signs,” 29% had two signs, 37% presented with one sign, and 19% had none.[8] Mental status changes are the most prevalent sign (seen in 82% of the cases), followed by eye signs (in 29%) and ataxia (23%).[8] WKS should be suspected in persons with a history of alcohol use and presenting with signs of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma, or unconsciousness.[9] Operational criteria for the diagnosis of Wernicke encephalopathy have been proposed by Caine et al.[10] that requires two out of four features, i.e., (a) dietary deficiency (signs such as cheilitis, glossitis, and bleeding gums), (b) oculomotor abnormalities (nystagmus, opthalmoplegia, and diplopia), (c) cerebellar dysfunction (gait ataxia, nystagmus), and (d) either altered mental state (confusion) or mild memory impairment.As it is very difficult to clinically distinguish Wernicke encephalopathy from other associated conditions such as delirium tremens, hepatic encephalopathy, or head injury, it is prudent to have a lower threshold to diagnose this if any of the clinical signs is seen. Magnetic resonance imaging (MRI) brain scan during Wernicke encephalopathy shows mammillary body atrophy and enlarged third ventricle, lesions in the medial portions of thalami and mid brain and can be used to aid diagnosis.[11],[12] However, most clinical situations warrant treatment without waiting for neuroimaging report.

The treatment suggestions in the guidelines vary widely. Furthermore, hardly any evidence-based recommendations exist on a more general use of thiamine as a preventative intervention in individuals with alcohol use disorder.[13] There are very few studies that have evaluated the dose and duration of thiamine for WKS, but higher doses may result in a greater response.[6],[14] With thiamine administration rapid improvement is seen in eye movement abnormalities (improve within days or weeks) and ataxia (may take months to recover), but the effects on memory, in particular, are unclear.[4],[14] Severe memory impairment is the core feature of Korsakoff syndrome. Initial stages of the disease can present with confabulation, executive dysfunction, flattened affect, apathy, and poor insight.[15] Both the episodic and semantic memory are affected, whereas, procedural memory remains intact.[15]Thomson et al.[6] suggested the following should be treated with thiamine as they are at high risk for developing WKS.

(1) all patients with any evidence of chronic alcohol misuse and any of the following. Acute confusion, decreased conscious level, ataxia, ophthalmoplegia, memory disturbance, and hypothermia with hypotension. (2) patients with delirium tremens may often also have Wernicke encephalopathy, therefore, all of these patients should be presumed to have Wernicke encephalopathy and treated, preferably as inpatients.

And (3) all hypoglycemic patients (who are treated with intravenous glucose) with evidence of chronic alcohol ingestion must be given intravenous thiamine immediately because of the risk of acutely precipitating Wernicke encephalopathy.Alcoholic cerebellar syndromeChronic alcohol use is associated with the degeneration of anterior superior vermis, leading to a clinical syndrome characterized by the subacute or chronic onset of gait ataxia and incoordination in legs, with relative sparing of upper limbs, speech, and oculomotor movements.[16] In severe cases, truncal ataxia, mild dysarthria, and incoordination of the upper limb is also found along with gait ataxia. Thiamine deficiency is considered to be the etiological factor,[17],[18] although direct toxic effects of alcohol may also contribute to this syndrome. One-third of patients with chronic use of alcohol have evidence of alcoholic cerebellar degeneration.

However, population-based studies estimate prevalence to be 14.6%.[19] The effect of alcohol on the cerebellum is graded with the most severe deficits occurring in alcohol users with the longest duration and highest severity of use. The diagnosis of cerebellar degeneration is largely clinical. MRI can be used to evaluate for vermian atrophy but is unnecessary.[20] Anterior portions of vermis are affected early, with involvement of posterior vermis and adjacent lateral hemispheres occurring late in the course could be used to differentiate alcoholic cerebellar degeneration from other conditions that cause more diffuse involvement.[21] The severity of cerebellar syndrome is more in the presence of WKS, thus could be related to thiamine deficiency.[22],[23] Therefore, this has been considered as a cerebellar presentation of WKS and should be treated in a similar way.[16] There are anecdotal evidence to suggest improvement in cerebellar syndrome with high-dose thiamine.[24]Alcoholic peripheral neuropathyPeripheral neuropathy is common in alcohol use disorder and is seen in 44% of the users.[25] It has been associated predominantly with thiamine deficiency.

However, deficiency of other B vitamins (pyridoxine and cobalamin) and direct toxic effect of alcohol is also implicated.[26] Clinically, onset of symptoms is gradual with the involvement of both sensory and motor fibers and occasionally autonomic fibers. Neuropathy can affect both small and large peripheral nerve fibers, leading to different clinical manifestations. Thiamine deficiency-related neuropathy affects larger fiber types, which results in motor deficits and sensory ataxia.

On examination, large fiber involvement is manifested by distal limb muscle weakness and loss of proprioception and vibratory sensation. Together, these can contribute to the gait unsteadiness seen in chronic alcohol users by creating a superimposed steppage gait and reduced proprioceptive input back to the movement control loops in the central nervous system. The most common presentations include painful sensations in both lower limbs, sometimes with burning sensation or numbness, which are early symptoms.

Typically, there is a loss of vibration sensation in distal lower limbs. Later symptoms include loss of proprioception, gait disturbance, and loss of reflexes. Most advanced findings include weakness and muscle atrophy.[20] Progression is very gradual over months and involvement of upper limbs may occur late in the course.

Diagnosis begins with laboratory evaluation to exclude other causes of distal, sensorimotor neuropathy including hemoglobin A1c, liver function tests, and complete blood count to evaluate for red blood cell macrocytosis. Cerebrospinal fluid studies may show increased protein levels but should otherwise be normal in cases of alcohol neuropathy and are not recommended in routine evaluation. Electromyography and nerve conduction studies can be used to distinguish whether the neuropathy is axonal or demyelinating and whether it is motor, sensory, or mixed type.

Alcoholic neuropathy shows reduced distal, sensory amplitudes, and to a lesser extent, reduced motor amplitudes on nerve conduction studies.[20] Abstinence and vitamin supplementation including thiamine are the treatments advocated for this condition.[25] In mild-to-moderate cases, near-complete improvement can be achieved.[20] Randomized controlled trials have showed a significant improvement in alcoholic polyneuropathy with thiamine treatment.[27],[28]Marchiafava–Bignami syndromeThis is a rare but fatal condition seen in chronic alcohol users that is characterized by progressive demyelination and necrosis of the corpus callosum. The association of this syndrome with thiamine deficiency is not very clear, and direct toxic effects of alcohol are also suggested.[29] The clinical syndrome is variable and presentation can be acute, subacute, or chronic. In acute forms, it is predominantly characterized by the altered mental state such as delirium, stupor, or coma.[30] Other clinical features in neuroimaging confirmed Marchiafava–Bignami syndrome (MBS) cases include impaired gait, dysarthria, mutism, signs of split-brain syndrome, pyramidal tract signs, primitive reflexes, rigidity, incontinence, gaze palsy, diplopia, and sensory symptoms.[30] Neuropsychiatric manifestations are common and include psychotic symptoms, depression, apathy, aggressive behavior, and sometimes dementia.[29] MRI scan shows lesions of the corpus callosum, particularly splenium.

Treatment for this condition is mostly supportive and use of nutritional supplements and steroids. However, there are several reports of improvement of this syndrome with thiamine at variable doses including reports of beneficial effects with high-dose strategy.[29],[30],[31] Early initiation of thiamine, preferably within 2 weeks of the onset of symptoms is associated with a better outcome. Therefore, high-dose thiamine should be administered to all suspected cases of MBS.

Laboratory Diagnosis of Thiamine Deficiency Estimation of thiamine and thiamine pyrophosphate levels may confirm the diagnosis of deficiency. Levels of thiamine in the blood are not reliable indicators of thiamine status. Low erythrocyte transketolase activity is also helpful.[32],[33] Transketolase concentrations of <120 nmol/L have also been used to indicate deficiency, while concentrations of 120–150 nmol/L suggest marginal thiamine status.[1] However, these tests are not routinely performed as it is time consuming, expensive, and may not be readily available.[34] The ETKA assay is a functional test rather than a direct measurement of thiamin status and therefore may be influenced by factors other than thiamine deficiency such as diabetes mellitus and polyneuritis.[1] Hence, treatment should be initiated in the absence of laboratory confirmation of thiamine deficiency.

Furthermore, treatment should not be delayed if tests are ordered, but the results are awaited. Electroencephalographic abnormalities in thiamine deficiency states range from diffuse mild-to-moderate slow waves and are not a good diagnostic option, as the prevalence of abnormalities among patients is inconsistent.[35]Surrogate markers, which reflect chronic alcohol use and nutritional deficiency other than thiamine, may be helpful in identifying at-risk patients. This includes gamma glutamate transferase, aspartate aminotransferase.

Alanine transaminase ratio >2:1, and increased mean corpuscular volume.[36] They are useful when a reliable history of alcohol use is not readily available, specifically in emergency departments when treatment needs to be started immediately to avoid long-term consequences. Thiamine Replacement Therapy Oral versus parenteral thiamineIntestinal absorption of thiamine depends on active transport through thiamine transporter 1 and 2, which follow saturation kinetics.[1] Therefore, the rate and amount of absorption of thiamine in healthy individuals is limited. In healthy volunteers, a 10 mg dose results in maximal absorption of thiamine, and any doses higher than this do not increase thiamine levels.

Therefore, the maximum amount of thiamine absorbed from 10 mg or higher dose is between 4.3 and 5.6 mg.[37] However, it has been suggested that, although thiamine transport occurs through the energy-requiring, sodium-dependent active process at physiologic concentrations, at higher supraphysiologic concentrations thiamine uptake is mostly a passive process.[38] Smithline et al. Have demonstrated that it is possible to achieve higher serum thiamine levels with oral doses up to 1500 mg.[39]In chronic alcohol users, intestinal absorption is impaired. Hence, absorption rates are expected to be much lower.

It is approximately 30% of that seen in healthy individuals, i.e., 1.5 mg of thiamine is absorbed from 10 mg oral thiamine.[3] In those consuming alcohol and have poor nutrition, not more than 0.8 mg of thiamine is absorbed.[2],[3],[6] The daily thiamine requirement is 1–1.6 mg/day, which may be more in alcohol-dependent patients at risk for Wernicke encephalopathy.[1] It is highly likely that oral supplementation with thiamine will be inadequate in alcohol-dependent individuals who continue to drink. Therefore, parenteral thiamine is preferred for supplementation in deficiency states associated with chronic alcohol use. Therapy involving parenteral thiamine is considered safe except for occasional circumstances of allergic reactions involving pruritus and local irritation.There is a small, but definite risk of anaphylaxis with parenteral thiamine, specifically with intravenous administration (1/250,000 intravenous injections).[40] Diluting thiamine in 50–100 mg normal saline for infusion may reduce the risk.

However, parenteral thiamine should always be administered under observation with the necessary facilities for resuscitation.A further important issue involves the timing of administration of thiamine relative to the course of alcohol abuse or dependence. Administration of thiamine treatment to patients experiencing alcohol withdrawal may also be influenced by other factors such as magnesium depletion, N-methyl-D-aspartate (NMDA) receptor upregulation, or liver impairment, all of which may alter thiamine metabolism and utilization.[6],[14]Thiamine or other preparations (e.g., benfotiamine)The thiamine transporters limit the rate of absorption of orally administered thiamine. Allithiamines (e.g., benfotiamine) are the lipid-soluble thiamine derivatives that are absorbed better, result in higher thiamine levels, and are retained longer in the body.[41] The thiamine levels with orally administered benfotiamine are much higher than oral thiamine and almost equals to intravenous thiamine given at the same dosage.[42]Benfotiamine has other beneficial effects including inhibition of production of advanced glycation end products, thus protecting against diabetic vascular complications.[41] It also modulates nuclear transcription factor κB (NK-κB), vascular endothelial growth factor receptor 2, glycogen synthase kinase 3 β, etc., that play a role in cell repair and survival.[41] Benfotiamine has been found to be effective for the treatment of alcoholic peripheral neuropathy.[27]Dosing of thiamineAs the prevalence of thiamine deficiency is very common in chronic alcohol users, the requirement of thiamine increases in active drinkers and it is difficult to rapidly determine thiamine levels using laboratory tests, it is prudent that all patients irrespective of nutritional status should be administered parenteral thiamine.

The dose should be 100 mg thiamine daily for 3–5 days during inpatient treatment. Commonly, multivitamin injections are added to intravenous infusions. Patients at risk for thiamine deficiency should receive 250 mg of thiamine daily intramuscularly for 3–5 days, followed by oral thiamine 100 mg daily.[6]Thiamine plasma levels reduce to 20% of peak value after approximately 2 h of parenteral administration, thus reducing the effective “window period” for passive diffusion to the central nervous system.[6] Therefore, in thiamine deficient individuals with features of Wernicke encephalopathy should receive thiamine thrice daily.High-dose parenteral thiamine administered thrice daily has been advocated in patients at risk for Wernicke encephalopathy.[43] The Royal College of Physicians guideline recommends that patients with suspected Wernicke encephalopathy should receive 500 mg thiamine diluted in 50–100 ml of normal saline infusion over 30 min three times daily for 2–3 days and sometimes for longer periods.[13] If there are persistent symptoms such as confusion, cerebellar symptoms, or memory impairment, this regimen can be continued until the symptoms improve.

If symptoms improve, oral thiamine 100 mg thrice daily can be continued for prolonged periods.[6],[40] A similar treatment regimen is advocated for alcoholic cerebellar degeneration as well. Doses more than 500 mg intramuscular or intravenous three times a day for 3–5 days, followed by 250 mg once daily for a further 3–5 days is also recommended by some guidelines (e.g., British Association for Psychopharmacology).[44]Other effects of thiamineThere are some data to suggest that thiamine deficiency can modulate alcohol consumption and may result in pathological drinking. Benfotiamine 600 mg/day as compared to placebo for 6 months was well tolerated and found to decrease psychiatric distress in males and reduce alcohol consumption in females with severe alcohol dependence.[45],[46] Other Factors During Thiamine Therapy Correction of hypomagnesemiaMagnesium is a cofactor for many thiamine-dependent enzymes in carbohydrate metabolism.

Patients may fail to respond to thiamine supplementation in the presence of hypomagnesemia.[47] Magnesium deficiency is common in chronic alcohol users and is seen in 30% of individuals.[48],[49] It can occur because of increased renal excretion of magnesium, poor intake, decreased absorption because of Vitamin D deficiency, the formation of undissociated magnesium soaps with free fatty acids.[48],[49]The usual adult dose is 35–50 mmol of magnesium sulfate added to 1 L isotonic (saline) given over 12–24 h.[6] The dose has to be titrated against plasma magnesium levels. It is recommended to reduce the dose in renal failure. Contraindications include patients with documented hypersensitivity and those with heart block, Addison's disease, myocardial damage, severe hepatitis, or hypophosphatemia.

Do not administer intravenous magnesium unless hypomagnesemia is confirmed.[6]Other B-complex vitaminsMost patients with deficiency of thiamine will also have reduced levels of other B vitamins including niacin, pyridoxine, and cobalamin that require replenishment. For patients admitted to the intensive care unit with symptoms that may mimic or mask Wernicke encephalopathy, based on the published literature, routine supplementation during the 1st day of admission includes 200–500 mg intravenous thiamine every 8 h, 64 mg/kg magnesium sulfate (≈4–5 g for most adult patients), and 400–1000 μg intravenous folate.[50] If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.[50] Precautions to be Taken When Administering Parenteral Thiamine It is recommended to monitor for anaphylaxis and has appropriate facilities for resuscitation and for treating anaphylaxis readily available including adrenaline and corticosteroids. Anaphylaxis has been reported at the rate of approximately 4/1 million pairs of ampoules of Pabrinex (a pair of high potency vitamins available in the UK containing 500 mg of thiamine (1:250,000 I/V administrations).[40] Intramuscular thiamine is reported to have a lower incidence of anaphylactic reactions than intravenous administration.[40] The reaction has been attributed to nonspecific histamine release.[51] Administer intravenous thiamine slowly, preferably by slow infusion in 100 ml normal saline over 15–30 min.

Conclusions Risk factors for thiamine deficiency should be assessed in chronic alcohol users. A high index of suspicion and a lower threshold to diagnose thiamine deficiency states including Wernicke encephalopathy is needed. Several other presentations such as cerebellar syndrome, MBS, polyneuropathy, and delirium tremens could be related to thiamine deficiency and should be treated with protocols similar to Wernicke encephalopathy.

High-dose thiamine is recommended for the treatment of suspected Wernicke encephalopathy and related conditions [Figure 1]. However, evidence in terms of randomized controlled trials is lacking, and the recommendations are based on small studies and anecdotal reports. Nevertheless, as all these conditions respond to thiamine supplementation, it is possible that these have overlapping pathophysiology and are better considered as Wernicke encephalopathy spectrum disorders.Figure 1.

Thiamine recommendations for patients with alcohol use disorder. AHistory of alcohol use, but no clinical features of WE. BNo clinical features of WE, but with risk factors such as complicated withdrawal (delirium, seizures).

CClinical features of WE (ataxia, opthalmoplegia, global confusion)Click here to viewFinancial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Frank LL. Thiamin in clinical practice.

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Drug Alcohol Rev 1990;9:53-60. 23.Baker KG, Harding AJ, Halliday GM, Kril JJ, Harper CG. Neuronal loss in functional zones of the cerebellum of chronic alcoholics with and without Wernicke's encephalopathy.

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A systematic review and meta-analysis. J Neurol 2018;22:1-3. 26.Chopra K, Tiwari V.

Alcoholic neuropathy. Possible mechanisms and future treatment possibilities. Br J Clin Pharmacol 2012;73:348-62.

27.Woelk H, Lehrl S, Bitsch R, Köpcke W. Benfotiamine in treatment of alcoholic polyneuropathy. An 8-week randomized controlled study (BAP I Study).

Alcohol Alcohol 1998;33:631-8. 28.Peters TJ, Kotowicz J, Nyka W, Kozubski W, Kuznetsov V, Vanderbist F, et al. Treatment of alcoholic polyneuropathy with vitamin B complex.

A randomised controlled trial. Alcohol Alcohol 2006;41:636-42. 29.Fernandes LM, Bezerra FR, Monteiro MC, Silva ML, de Oliveira FR, Lima RR, et al.

Thiamine deficiency, oxidative metabolic pathways and ethanol-induced neurotoxicity. How poor nutrition contributes to the alcoholic syndrome, as Marchiafava-Bignami disease. Eur J Clin Nutr 2017;71:580-6.

30.Hillbom M, Saloheimo P, Fujioka S, Wszolek ZK, Juvela S, Leone MA. Diagnosis and management of Marchiafava-Bignami disease. A review of CT/MRI confirmed cases.

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Thiamine assays – Advances, challenges, and caveats. ChemistryOpen 2017;6:178-91. 35.Chandrakumar A, Bhardwaj A, 't Jong GW.

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Annu Rev Pharmacol Toxicol 1983;23:331-51. Correspondence Address:Samir Kumar PraharajDepartment of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_440_20 Figures [Figure 1].

How to ventolin price comparison cite this best site article:Singh OP. The National Commission for Allied and Healthcare Professions Act, 2020 and its implication for mental health. Indian J Psychiatry 2021;63:119-20The National Commission for Allied and Healthcare Professions Act, 2020 has been notified on ventolin price comparison March 28, 2021, by the Gazette of India published by the Ministry of Law and Justice. This bill aims to “provide for regulation and maintenance of standards of education and services by allied and healthcare professionals, assessment of institutions, maintenance of a Central Register and State Register and creation of a system to improve access, research and development and adoption of latest scientific advancement and for matters connected therewith or incidental thereto.”[1]This act has created a category of Health Care Professionals which is defined as. €œhealthcare professional” includes a scientist, therapist, or other professional who studies, advises, researches, supervises or provides preventive, curative, rehabilitative, therapeutic or promotional health services and who has obtained any qualification of degree under this Act, the duration of which shall not be <3600 h spread over a period of 3 years to ventolin price comparison 6 years divided into specific semesters.[1]According to the act, “Allied health professional” includes an associate, technician, or technologist who is trained to perform any technical and practical task to support diagnosis and treatment of illness, disease, injury or impairment, and to support implementation of any healthcare treatment and referral plan recommended by a medical, nursing, or any other healthcare professional, and who has obtained any qualification of diploma or degree under this Act, the duration of which shall not be less than 2000 h spread over a period of 2 years to 4 years divided into specific semesters.”[1]It is noticeable that while the term “Health Care Professionals” does not include doctors who are registered under National Medical Council, Mental Health Care Act (MHCA), 2017 includes psychiatrists under the ambit of Mental Health Care Professionals.[2] This discrepancy needs to be corrected - psychiasts, being another group of medical specialists, should be kept out of the broad umbrella of “Mental Healthcare Professionals.”The category of Behavioural Health Sciences Professional has been included and defined as “a person who undertakes scientific study of the emotions, behaviours and biology relating to a person's mental well-being, their ability to function in everyday life and their concept of self.

€œBehavioural health” is the preferred term to “mental health” and includes professionals such as counselors, analysts, psychologists, educators and support workers, who provide counseling, therapy, and mediation services to individuals, families, groups, and communities in response to social and personal difficulties.”[1]This is a welcome step to the extent that it creates a diverse category of trained workforce in the field of Mental Health (Behavioural Health Science Professionals) and tries to regulate their training although it mainly aims to promote mental wellbeing. However there is a huge lacuna ventolin price comparison in the term of “Mental Illness” as defined by MHCA, 2017. Only severe disorders are included as per definition and there is no clarity regarding inclusion of other psychiatric disorders, namely “common mental disorders” such as anxiety and depression. This leaves a strong possibility of concept of “psychiatric illnesses” being limited to only “severe psychiatric disorders” ventolin price comparison (major psychoses) thus perpetuating the stigma and alienation associated with psychiatric patients for centuries. Psychiatrists being restricted to treating severe mental disorders as per MHCA, 2017, there is a strong possibility that the care of common mental disorders may gradually pass on under the care of “behavioural health professionals” as per the new act!.

There is need to look into this aspect by the leadership in psychiatry, both organizational and academic ventolin price comparison psychiatry, and reduce the contradictions between the MHCA, 2017 and this nascent act. All disorders classified in ICD 10 and DSM 5 should be classified as “Psychiatric Disorders” or “Mental Illness.” This will not only help in fighting the stigma associated with psychiatric illnesses but also promote the integration of psychiatry with other specialties. References 1.The National Commission for Allied and Healthcare Professions ventolin price comparison Act, 2021. The Gazette of India. Published by Ministry of ventolin price comparison Law and Justice.

28 March, 2021. 2.The Mental Healthcare Act, 2017 ventolin price comparison. The Gazette of India. Published by Ministry of Law and Justice ventolin price comparison. April 7, 2017.

Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource ventolin price comparison of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_268_21Abstract Thiamine ventolin price comparison is essential for the activity of several enzymes associated with energy metabolism in humans. Chronic alcohol use is associated with deficiency of thiamine along with other vitamins through several mechanisms.

Several neuropsychiatric syndromes have been associated with thiamine deficiency in the context of alcohol use disorder including Wernicke–Korsakoff syndrome, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, and possibly, Marchiafava–Bignami ventolin price comparison syndrome. High-dose thiamine replacement is suggested for these neuropsychiatric syndromes.Keywords. Alcohol use disorder, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, ventolin price comparison Marchiafava–Bignami syndrome, thiamine, Wernicke–Korsakoff syndromeHow to cite this article:Praharaj SK, Munoli RN, Shenoy S, Udupa ST, Thomas LS. High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry 2021;63:121-6How to cite this URL:Praharaj SK, Munoli RN, Shenoy S, Udupa ST, ventolin price comparison Thomas LS.

High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J ventolin price comparison Psychiatry [serial online] 2021 [cited 2021 May 20];63:121-6. Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/2/121/313716 Introduction Thiamine is a water-soluble vitamin (B1) that plays a key role in the activity of several enzymes associated with energy metabolism.

Thiamine pyrophosphate (or diphosphate) is the active form that acts as a cofactor for enzymes. The daily dietary requirement of thiamine in adults is 1–2 mg and is dependent on carbohydrate intake.[1],[2] The requirement increases if basal metabolic rate is higher, for example, during alcohol withdrawal state. Dietary sources include pork (being the major source), meat, legume, vegetables, and enriched foods. The body can store between 30 and 50 mg of thiamine and is likely to get depleted within 4–6 weeks if the diet is deficient.[2] In those with alcohol-related liver damage, the ability to store thiamine is gradually reduced.[1],[2]Lower thiamine levels are found in 30%–80% of chronic alcohol users.[3] Thiamine deficiency occurs due to poor intake of vitamin-rich foods, impaired intestinal absorption, decreased storage capacity of liver, damage to the renal epithelial cells due to alcohol, leading to increased loss from the kidneys, and excessive loss associated with medical conditions.[2],[3] Furthermore, alcohol decreases the absorption of colonic bacterial thiamine, reduces the enzymatic activity of thiamine pyrophosphokinase, and thereby, reducing the amount of available thiamine pyrophosphate.[4] Since facilitated diffusion of thiamine into cells is dependent on a concentration gradient, reduced thiamine pyrophosphokinase activity further reduces thiamine uptake into cells.[4] Impaired utilization of thiamine is seen in certain conditions (e.g., hypomagnesemia) which are common in alcohol use disorder.[2],[3],[4] This narrative review discusses the neuropsychiatric syndromes associated with thiamine deficiency in the context of alcohol use disorder, and the treatment regimens advocated for these conditions. A PubMed search supplemented with manual search was used to identify neuropsychiatric syndromes related to thiamine deficiency in alcohol use disorder patients.

Neuropsychiatric Syndromes Associated With Thiamine Deficiency Wernicke–Korsakoff syndromeWernicke encephalopathy is associated with chronic alcohol use, and if not identified and treated early, could lead to permanent brain damage characterized by an amnestic syndrome known as Korsakoff syndrome. Inappropriate treatment of Wernicke encephalopathy with lower doses of thiamine can lead to high mortality rates (~20%) and Korsakoff syndrome in ~ 80% of patients (ranges from 56% to 84%).[5],[6] The classic triad of Wernicke includes oculomotor abnormalities, cerebellar dysfunction, and confusion. Wernicke lesions are found in 12.5% of brain samples of patients with alcohol dependence.[7] However, only 20%–30% of them had a clinical diagnosis of Wernicke encephalopathy antemortem. It has been found that many patients develop Wernicke–Korsakoff syndrome (WKS) following repeated subclinical episodes of thiamine deficiency.[7] In an autopsy report of 97 chronic alcohol users, only16% had all the three “classical signs,” 29% had two signs, 37% presented with one sign, and 19% had none.[8] Mental status changes are the most prevalent sign (seen in 82% of the cases), followed by eye signs (in 29%) and ataxia (23%).[8] WKS should be suspected in persons with a history of alcohol use and presenting with signs of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma, or unconsciousness.[9] Operational criteria for the diagnosis of Wernicke encephalopathy have been proposed by Caine et al.[10] that requires two out of four features, i.e., (a) dietary deficiency (signs such as cheilitis, glossitis, and bleeding gums), (b) oculomotor abnormalities (nystagmus, opthalmoplegia, and diplopia), (c) cerebellar dysfunction (gait ataxia, nystagmus), and (d) either altered mental state (confusion) or mild memory impairment.As it is very difficult to clinically distinguish Wernicke encephalopathy from other associated conditions such as delirium tremens, hepatic encephalopathy, or head injury, it is prudent to have a lower threshold to diagnose this if any of the clinical signs is seen. Magnetic resonance imaging (MRI) brain scan during Wernicke encephalopathy shows mammillary body atrophy and enlarged third ventricle, lesions in the medial portions of thalami and mid brain and can be used to aid diagnosis.[11],[12] However, most clinical situations warrant treatment without waiting for neuroimaging report.

The treatment suggestions in the guidelines vary widely. Furthermore, hardly any evidence-based recommendations exist on a more general use of thiamine as a preventative intervention in individuals with alcohol use disorder.[13] There are very few studies that have evaluated the dose and duration of thiamine for WKS, but higher doses may result in a greater response.[6],[14] With thiamine administration rapid improvement is seen in eye movement abnormalities (improve within days or weeks) and ataxia (may take months to recover), but the effects on memory, in particular, are unclear.[4],[14] Severe memory impairment is the core feature of Korsakoff syndrome. Initial stages of the disease can present with confabulation, executive dysfunction, flattened affect, apathy, and poor insight.[15] Both the episodic and semantic memory are affected, whereas, procedural memory remains intact.[15]Thomson et al.[6] suggested the following should be treated with thiamine as they are at high risk for developing WKS. (1) all patients with any evidence of chronic alcohol misuse and any of the following. Acute confusion, decreased conscious level, ataxia, ophthalmoplegia, memory disturbance, and hypothermia with hypotension.

(2) patients with delirium tremens may often also have Wernicke encephalopathy, therefore, all of these patients should be presumed to have Wernicke encephalopathy and treated, preferably as inpatients. And (3) all hypoglycemic patients (who are treated with intravenous glucose) with evidence of chronic alcohol ingestion must be given intravenous thiamine immediately because of the risk of acutely precipitating Wernicke encephalopathy.Alcoholic cerebellar syndromeChronic alcohol use is associated with the degeneration of anterior superior vermis, leading to a clinical syndrome characterized by the subacute or chronic onset of gait ataxia and incoordination in legs, with relative sparing of upper limbs, speech, and oculomotor movements.[16] In severe cases, truncal ataxia, mild dysarthria, and incoordination of the upper limb is also found along with gait ataxia. Thiamine deficiency is considered to be the etiological factor,[17],[18] although direct toxic effects of alcohol may also contribute to this syndrome. One-third of patients with chronic use of alcohol have evidence of alcoholic cerebellar degeneration. However, population-based studies estimate prevalence to be 14.6%.[19] The effect of alcohol on the cerebellum is graded with the most severe deficits occurring in alcohol users with the longest duration and highest severity of use.

The diagnosis of cerebellar degeneration is largely clinical. MRI can be used to evaluate for vermian atrophy but is unnecessary.[20] Anterior portions of vermis are affected early, with involvement of posterior vermis and adjacent lateral hemispheres occurring late in the course could be used to differentiate alcoholic cerebellar degeneration from other conditions that cause more diffuse involvement.[21] The severity of cerebellar syndrome is more in the presence of WKS, thus could be related to thiamine deficiency.[22],[23] Therefore, this has been considered as a cerebellar presentation of WKS and should be treated in a similar way.[16] There are anecdotal evidence to suggest improvement in cerebellar syndrome with high-dose thiamine.[24]Alcoholic peripheral neuropathyPeripheral neuropathy is common in alcohol use disorder and is seen in 44% of the users.[25] It has been associated predominantly with thiamine deficiency. However, deficiency of other B vitamins (pyridoxine and cobalamin) and direct toxic effect of alcohol is also implicated.[26] Clinically, onset of symptoms is gradual with the involvement of both sensory and motor fibers and occasionally autonomic fibers. Neuropathy can affect both small and large peripheral nerve fibers, leading to different clinical manifestations. Thiamine deficiency-related neuropathy affects larger fiber types, which results in motor deficits and sensory ataxia.

On examination, large fiber involvement is manifested by distal limb muscle weakness and loss of proprioception and vibratory sensation. Together, these can contribute to the gait unsteadiness seen in chronic alcohol users by creating a superimposed steppage gait and reduced proprioceptive input back to the movement control loops in the central nervous system. The most common presentations include painful sensations in both lower limbs, sometimes with burning sensation or numbness, which are early symptoms. Typically, there is a loss of vibration sensation in distal lower limbs. Later symptoms include loss of proprioception, gait disturbance, and loss of reflexes.

Most advanced findings include weakness and muscle atrophy.[20] Progression is very gradual over months and involvement of upper limbs may occur late in the course. Diagnosis begins with laboratory evaluation to exclude other causes of distal, sensorimotor neuropathy including hemoglobin A1c, liver function tests, and complete blood count to evaluate for red blood cell macrocytosis. Cerebrospinal fluid studies may show increased protein levels but should otherwise be normal in cases of alcohol neuropathy and are not recommended in routine evaluation. Electromyography and nerve conduction studies can be used to distinguish whether the neuropathy is axonal or demyelinating and whether it is motor, sensory, or mixed type. Alcoholic neuropathy shows reduced distal, sensory amplitudes, and to a lesser extent, reduced motor amplitudes on nerve conduction studies.[20] Abstinence and vitamin supplementation including thiamine are the treatments advocated for this condition.[25] In mild-to-moderate cases, near-complete improvement can be achieved.[20] Randomized controlled trials have showed a significant improvement in alcoholic polyneuropathy with thiamine treatment.[27],[28]Marchiafava–Bignami syndromeThis is a rare but fatal condition seen in chronic alcohol users that is characterized by progressive demyelination and necrosis of the corpus callosum.

The association of this syndrome with thiamine deficiency is not very clear, and direct toxic effects of alcohol are also suggested.[29] The clinical syndrome is variable and presentation can be acute, subacute, or chronic. In acute forms, it is predominantly characterized by the altered mental state such as delirium, stupor, or coma.[30] Other clinical features in neuroimaging confirmed Marchiafava–Bignami syndrome (MBS) cases include impaired gait, dysarthria, mutism, signs of split-brain syndrome, pyramidal tract signs, primitive reflexes, rigidity, incontinence, gaze palsy, diplopia, and sensory symptoms.[30] Neuropsychiatric manifestations are common and include psychotic symptoms, depression, apathy, aggressive behavior, and sometimes dementia.[29] MRI scan shows lesions of the corpus callosum, particularly splenium. Treatment for this condition is mostly supportive and use of nutritional supplements and steroids. However, there are several reports of improvement of this syndrome with thiamine at variable doses including reports of beneficial effects with high-dose strategy.[29],[30],[31] Early initiation of thiamine, preferably within 2 weeks of the onset of symptoms is associated with a better outcome. Therefore, high-dose thiamine should be administered to all suspected cases of MBS.

Laboratory Diagnosis of Thiamine Deficiency Estimation of thiamine and thiamine pyrophosphate levels may confirm the diagnosis of deficiency. Levels of thiamine in the blood are not reliable indicators of thiamine status. Low erythrocyte transketolase activity is also helpful.[32],[33] Transketolase concentrations of <120 nmol/L have also been used to indicate deficiency, while concentrations of 120–150 nmol/L suggest marginal thiamine status.[1] However, these tests are not routinely performed as it is time consuming, expensive, and may not be readily available.[34] The ETKA assay is a functional test rather than a direct measurement of thiamin status and therefore may be influenced by factors other than thiamine deficiency such as diabetes mellitus and polyneuritis.[1] Hence, treatment should be initiated in the absence of laboratory confirmation of thiamine deficiency. Furthermore, treatment should not be delayed if tests are ordered, but the results are awaited. Electroencephalographic abnormalities in thiamine deficiency states range from diffuse mild-to-moderate slow waves and are not a good diagnostic option, as the prevalence of abnormalities among patients is inconsistent.[35]Surrogate markers, which reflect chronic alcohol use and nutritional deficiency other than thiamine, may be helpful in identifying at-risk patients.

This includes gamma glutamate transferase, aspartate aminotransferase. Alanine transaminase ratio >2:1, and increased mean corpuscular volume.[36] They are useful when a reliable history of alcohol use is not readily available, specifically in emergency departments when treatment needs to be started immediately to avoid long-term consequences. Thiamine Replacement Therapy Oral versus parenteral thiamineIntestinal absorption of thiamine depends on active transport through thiamine transporter 1 and 2, which follow saturation kinetics.[1] Therefore, the rate and amount of absorption of thiamine in healthy individuals is limited. In healthy volunteers, a 10 mg dose results in maximal absorption of thiamine, and any doses higher than this do not increase thiamine levels. Therefore, the maximum amount of thiamine absorbed from 10 mg or higher dose is between 4.3 and 5.6 mg.[37] However, it has been suggested that, although thiamine transport occurs through the energy-requiring, sodium-dependent active process at physiologic concentrations, at higher supraphysiologic concentrations thiamine uptake is mostly a passive process.[38] Smithline et al.

Have demonstrated that it is possible to achieve higher serum thiamine levels with oral doses up to 1500 mg.[39]In chronic alcohol users, intestinal absorption is impaired. Hence, absorption rates are expected to be much lower. It is approximately 30% of that seen in healthy individuals, i.e., 1.5 mg of thiamine is absorbed from 10 mg oral thiamine.[3] In those consuming alcohol and have poor nutrition, not more than 0.8 mg of thiamine is absorbed.[2],[3],[6] The daily thiamine requirement is 1–1.6 mg/day, which may be more in alcohol-dependent patients at risk for Wernicke encephalopathy.[1] It is highly likely that oral supplementation with thiamine will be inadequate in alcohol-dependent individuals who continue to drink. Therefore, parenteral thiamine is preferred for supplementation in deficiency states associated with chronic alcohol use. Therapy involving parenteral thiamine is considered safe except for occasional circumstances of allergic reactions involving pruritus and local irritation.There is a small, but definite risk of anaphylaxis with parenteral thiamine, specifically with intravenous administration (1/250,000 intravenous injections).[40] Diluting thiamine in 50–100 mg normal saline for infusion may reduce the risk.

However, parenteral thiamine should always be administered under observation with the necessary facilities for resuscitation.A further important issue involves the timing of administration of thiamine relative to the course of alcohol abuse or dependence. Administration of thiamine treatment to patients experiencing alcohol withdrawal may also be influenced by other factors such as magnesium depletion, N-methyl-D-aspartate (NMDA) receptor upregulation, or liver impairment, all of which may alter thiamine metabolism and utilization.[6],[14]Thiamine or other preparations (e.g., benfotiamine)The thiamine transporters limit the rate of absorption of orally administered thiamine. Allithiamines (e.g., benfotiamine) are the lipid-soluble thiamine derivatives that are absorbed better, result in higher thiamine levels, and are retained longer in the body.[41] The thiamine levels with orally administered benfotiamine are much higher than oral thiamine and almost equals to intravenous thiamine given at the same dosage.[42]Benfotiamine has other beneficial effects including inhibition of production of advanced glycation end products, thus protecting against diabetic vascular complications.[41] It also modulates nuclear transcription factor κB (NK-κB), vascular endothelial growth factor receptor 2, glycogen synthase kinase 3 β, etc., that play a role in cell repair and survival.[41] Benfotiamine has been found to be effective for the treatment of alcoholic peripheral neuropathy.[27]Dosing of thiamineAs the prevalence of thiamine deficiency is very common in chronic alcohol users, the requirement of thiamine increases in active drinkers and it is difficult to rapidly determine thiamine levels using laboratory tests, it is prudent that all patients irrespective of nutritional status should be administered parenteral thiamine. The dose should be 100 mg thiamine daily for 3–5 days during inpatient treatment. Commonly, multivitamin injections are added to intravenous infusions.

Patients at risk for thiamine deficiency should receive 250 mg of thiamine daily intramuscularly for 3–5 days, followed by oral thiamine 100 mg daily.[6]Thiamine plasma levels reduce to 20% of peak value after approximately 2 h of parenteral administration, thus reducing the effective “window period” for passive diffusion to the central nervous system.[6] Therefore, in thiamine deficient individuals with features of Wernicke encephalopathy should receive thiamine thrice daily.High-dose parenteral thiamine administered thrice daily has been advocated in patients at risk for Wernicke encephalopathy.[43] The Royal College of Physicians guideline recommends that patients with suspected Wernicke encephalopathy should receive 500 mg thiamine diluted in 50–100 ml of normal saline infusion over 30 min three times daily for 2–3 days and sometimes for longer periods.[13] If there are persistent symptoms such as confusion, cerebellar symptoms, or memory impairment, this regimen can be continued until the symptoms improve. If symptoms improve, oral thiamine 100 mg thrice daily can be continued for prolonged periods.[6],[40] A similar treatment regimen is advocated for alcoholic cerebellar degeneration as well. Doses more than 500 mg intramuscular or intravenous three times a day for 3–5 days, followed by 250 mg once daily for a further 3–5 days is also recommended by some guidelines (e.g., British Association for Psychopharmacology).[44]Other effects of thiamineThere are some data to suggest that thiamine deficiency can modulate alcohol consumption and may result in pathological drinking. Benfotiamine 600 mg/day as compared to placebo for 6 months was well tolerated and found to decrease psychiatric distress in males and reduce alcohol consumption in females with severe alcohol dependence.[45],[46] Other Factors During Thiamine Therapy Correction of hypomagnesemiaMagnesium is a cofactor for many thiamine-dependent enzymes in carbohydrate metabolism. Patients may fail to respond to thiamine supplementation in the presence of hypomagnesemia.[47] Magnesium deficiency is common in chronic alcohol users and is seen in 30% of individuals.[48],[49] It can occur because of increased renal excretion of magnesium, poor intake, decreased absorption because of Vitamin D deficiency, the formation of undissociated magnesium soaps with free fatty acids.[48],[49]The usual adult dose is 35–50 mmol of magnesium sulfate added to 1 L isotonic (saline) given over 12–24 h.[6] The dose has to be titrated against plasma magnesium levels.

It is recommended to reduce the dose in renal failure. Contraindications include patients with documented hypersensitivity and those with heart block, Addison's disease, myocardial damage, severe hepatitis, or hypophosphatemia. Do not administer intravenous magnesium unless hypomagnesemia is confirmed.[6]Other B-complex vitaminsMost patients with deficiency of thiamine will also have reduced levels of other B vitamins including niacin, pyridoxine, and cobalamin that require replenishment. For patients admitted to the intensive care unit with symptoms that may mimic or mask Wernicke encephalopathy, based on the published literature, routine supplementation during the 1st day of admission includes 200–500 mg intravenous thiamine every 8 h, 64 mg/kg magnesium sulfate (≈4–5 g for most adult patients), and 400–1000 μg intravenous folate.[50] If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.[50] Precautions to be Taken When Administering Parenteral Thiamine It is recommended to monitor for anaphylaxis and has appropriate facilities for resuscitation and for treating anaphylaxis readily available including adrenaline and corticosteroids. Anaphylaxis has been reported at the rate of approximately 4/1 million pairs of ampoules of Pabrinex (a pair of high potency vitamins available in the UK containing 500 mg of thiamine (1:250,000 I/V administrations).[40] Intramuscular thiamine is reported to have a lower incidence of anaphylactic reactions than intravenous administration.[40] The reaction has been attributed to nonspecific histamine release.[51] Administer intravenous thiamine slowly, preferably by slow infusion in 100 ml normal saline over 15–30 min.

Conclusions Risk factors for thiamine deficiency should be assessed in chronic alcohol users. A high index of suspicion and a lower threshold to diagnose thiamine deficiency states including Wernicke encephalopathy is needed. Several other presentations such as cerebellar syndrome, MBS, polyneuropathy, and delirium tremens could be related to thiamine deficiency and should be treated with protocols similar to Wernicke encephalopathy. High-dose thiamine is recommended for the treatment of suspected Wernicke encephalopathy and related conditions [Figure 1]. However, evidence in terms of randomized controlled trials is lacking, and the recommendations are based on small studies and anecdotal reports.

Nevertheless, as all these conditions respond to thiamine supplementation, it is possible that these have overlapping pathophysiology and are better considered as Wernicke encephalopathy spectrum disorders.Figure 1. Thiamine recommendations for patients with alcohol use disorder. AHistory of alcohol use, but no clinical features of WE. BNo clinical features of WE, but with risk factors such as complicated withdrawal (delirium, seizures). CClinical features of WE (ataxia, opthalmoplegia, global confusion)Click here to viewFinancial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

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10.4103/psychiatry.IndianJPsychiatry_440_20 Figures [Figure 1].