Lybrate.com has a number of highly qualified Pulmonologists in India. You will find Pulmonologists with more than 43 years of experience on Lybrate.com. You can find Pulmonologists online in Nagpur and from across India. View the profile of medical specialists and their reviews from other patients to make an informed decision.
Book Clinic Appointment
Oxygen Therapy Treatment
Management of Smoking Cessation
Asthma Management Program
Lower/Upper Respiratory Tract Infection Treatment
Obstructive Sleep Apnea Treatment
Treatment of Sleep Disturbance
Submit a review for Dr. Rajesh SwarnakarYour feedback matters!
Smoking can cause irreparable damage to your mind and body. Chemicals in the tobacco travel to all parts of the body, leaving no area unaffected. According to available data, smoking causes 30% of all cancer deaths and about 80% deaths from emphysema and bronchitis. In addition to adversely affecting yourself, smoking also has a severe impact on your near and dear ones. According to WHO, about 600,000 people die every year from passive smoking. Out of the deaths that occur due to this, 1/3rd is that of children.
The Indian situation
While 85% of tobacco users worldwide consume it in the form of cigarettes, in India only 13% use it in that form. Additionally, 54% use it in the form of beedis. A study conducted on Indian smokers has revealed that an average of 8.2 cigarettes is smoked by an individual daily.
The study also revealed that the number of cigarettes smoked every year had grown to over 6 trillion. While 1 out of 10 adults dies from tobacco use worldwide, 5% of deaths in women and 20% of deaths in men in India are caused by cigarette and beedi smoking.
What happens when you smoke?
Cigarette smoke is made up of 4000 chemicals that are present either as tiny particles or gases and about 50 are known to lead to cancer, the toxin nicotine being one of them. In addition to nicotine, the chemicals that make up cigarette smoke also include tar and carbon monoxide. Prolonged exposure to these toxins can hamper your body's ability to filter air and clean the lungs. The smoke not only irritates the lungs but also causes excess production of mucus.
It also causes a paralysis of the tiny hair-like structures like cilia that line the airways and are responsible for removing dust and dirt from the organ. Paralysis of these hair-like structures also causes a buildup of mucus and toxic substances, leading to lung congestion. The extra mucus that is produced causes smokers to suffer from the very ubiquitous smoker's cough and chronic bronchitis.
It's also one of the many triggers of asthma, which brings about the narrowing and inflammation of the airways. Long-term exposure to tobacco smoke causes the destruction of the structure of the lung, walls of the airways as well as lung tissue. The result is a condition known as emphysema. Additionally, smoking also leads to cancer of the lung and over 80% lung cancer cases occur due to this habit. If you wish to discuss about any specific problem, you can consult a pulmonologist.
If you find yourself suffering from coughing spells accompanied by breathlessness and phlegm, you may have bronchitis. Bronchitis is a respiratory disease that causes an inflammation of the bronchial tubes. This narrows the airway and does not allow sufficient oxygen to reach the lungs. There are two types of bronchitis; acute bronchitis that lasts for 1-3 weeks and chronic bronchitis that persists for 3 months to 2 years.
Causes of acute bronchitis
Acute bronchitis is usually a result of viral, lung infections. It can also be caused by bacterial infections and exposure to irritants such as tobacco smoke, dust, vapours and particulate matter in the air.
Causes of chronic bronchitis
Repeated attacks of acute bronchitis can weaken the bronchial passage with time and lead to the development of chronic bronchitis. This condition can also be caused by prolonged exposure to dust, pollution and industrial fumes. This puts coal miners, grain handlers and metal workers at a high risk of suffering from this disease. Smoking cigarettes can also irritate the bronchial tubes and contribute to the development of this condition. Chronic bronchitis worsens when a person is exposed to high levels of sulpher dioxide and other such air pollutants for prolonged time periods. Some of the symptoms of bronchitis are:
- A persistent cough
- Tightening of the chest
If these symptoms last for over a week or begin to interfere with your regular lifestyle, you should seek medical attention as soon as possible. Self-medicating with an over the counter cough suppressant is counterproductive in the case of bronchitis as a cough is the only way for phlegm and mucus to be expelled from the body. Conventional treatment for bronchitis includes
- Getting lots of rest
- Drinking plenty of fluids
- Avoiding exposure to smoke and dust
- Steam inhalations
Along with this, your doctor may also prescribe cough medicines and a bronchial inhalator. In cases of chronic bronchitis, oral or inhaled steroids may also be needed. Your doctor may also suggest a flu vaccine as bronchitis make your lungs vulnerable to further infections. If you smoke, your doctor will also urge you to quit as cigarette smoke can aggravate your symptoms.
In cases of severe chronic bronchitis where the bronchial tube’s ability to pass oxygen is compromised, oxygen therapy may be needed. In such cases, you may need to have an oxygen tank on hand to be used continuously or as required.
What is sinusitis? — Sinusitis is a condition that can cause a stuffy nose, pain in the face, and yellow or green discharge (mucus) from the nose. The sinuses are hollow areas in the bones of the face. They have a thin lining that normally makes a small amount of mucus. When this lining gets infected, it swells and makes extra mucus. This causes symptoms.
Sinusitis can occur when a person gets sick with a cold. The germs causing the cold can also infect the sinuses. Many times, a person feels like his or her cold is getting better. But then he or she gets sinusitis and begins to feel sick again.
What are the symptoms of sinusitis? — Common symptoms of sinusitis include:
Stuffy or blocked noseThick yellow or green discharge from the nosePain in the teethPain or pressure in the face – This often feels worse when a person bends forward.
People with sinusitis can also have other symptoms that include:
FeverCoughTrouble smellingEar pressure or fullnessHeadacheBad breathFeeling tired
Most of the time, symptoms start to improve in 7 to 10 days.
Should I see a doctor or nurse? — See your doctor or nurse if your symptoms last more than 7 days, or if your symptoms get better at first but then get worse.
Sometimes, sinusitis can lead to serious problems. See your doctor or nurse right away (do not wait 7 days) if you have:
Fever higher than 102.5°F (39.2°C)Sudden and severe pain in the face and headTrouble seeing or seeing doubleTrouble thinking clearlySwelling or redness around 1 or both eyesTrouble breathing or a stiff neck
Is there anything I can do on my own to feel better? — Yes. To reduce your symptoms, you can:
Take an over-the-counter pain reliever to reduce the painRinse your nose and sinuses with salt water a few times a day – Ask your doctor or nurse about the best way to do this.Use a decongestant nose spray – These sprays are sold in a pharmacy. But do not use decongestant nose sprays for more than 2 to 3 days in a row. Using them more than 3 days in a row can make symptoms worse.
You should NOT take an antihistamine for sinusitis. Common antihistamines include diphenhydramine(sample brand name: Benadryl), chlorpheniramine(sample brand name: Chlor-Trimeton), loratadine(sample brand name: Claritin), and cetirizine (sample brand name: Zyrtec). They can treat allergies, but not sinus infections, and could increase your discomfort by drying the lining of your nose and sinuses, or making you tired.
Your doctor might also prescribe a steroid nose spray to reduce the swelling in your nose. (Steroid nose sprays do not contain the same steroids that athletes take to build muscle.)
How is sinusitis treated? — Most of the time, sinusitis does not need to be treated with antibiotic medicines. This is because most sinusitis is caused by viruses — not bacteria — and antibiotics do not kill viruses. Many people get over sinus infections without antibiotics.
Some people with sinusitis do need treatment with antibiotics. If your symptoms have not improved after 7 to 10 days, ask your doctor if you should take antibiotics. Your doctor might recommend that you wait 1 more week to see if your symptoms improve. But if you have symptoms such as a fever or a lot of pain, he or she might prescribe antibiotics. It is important to follow your doctor’s instructions about taking your antibiotics.
What if my symptoms do not get better? — If your symptoms do not get better, talk with your doctor or nurse. He or she might order tests to figure out why you still have symptoms. These can include:
CT scan or other imaging tests – Imaging tests create pictures of the inside of the body.A test to look inside the sinuses – For this test, a doctor puts a thin tube with a camera on the end into the nose and up into the sinuses.
Some people get a lot of sinus infections or have symptoms that last at least 3 months. These people can have a different type of sinusitis called “chronic sinusitis.” Chronic sinusitis can be caused by different things. For example, some people have growths in their nose or sinuses that are called “polyps.” Other people have allergies that cause their symptoms.
Chronic sinusitis can be treated in different ways. If you have chronic sinusitis, talk with your doctor about which treatments are right for you.
What are seasonal allergies? — Seasonal allergies, also called “hay fever,” are a group of conditions that can cause sneezing, a stuffy nose, or a runny nose. Symptoms occur only at certain times of the year. Most seasonal allergies are caused by:
●Pollens from trees, grasses, or weeds
●Mold spores, which grow when the weather is humid, wet, or damp
Normally, people breathe in these substances without a problem. When a person has a seasonal allergy, his or her immune system acts as if the substance is harmful to the body. This causes symptoms.
Many people first get seasonal allergies when they are children. Seasonal allergies are life long, but symptoms can get better or worse over time. Seasonal allergies sometimes run in families.
Some people have symptoms like those of seasonal allergies, but their symptoms last all year. Year-round symptoms are usually caused by:
●Insects, such as dust mites and cockroaches
●Animals, such as cats and dogs
Many children with seasonal allergies also have asthma. (Asthma is a condition that can make it hard to breathe.)
What are the symptoms of seasonal allergies? — Symptoms of seasonal allergies can include:
●Stuffy nose, runny nose, or sneezing a lot
●Itchy or red eyes
●Sore throat, or itchy throat or ears
●Waking up at night or trouble sleeping, which can lead to feeling tired or having trouble concentrating during the day
Young children often do not blow their nose but instead sniff, cough, or clear their throat a lot. They might also get into the habit of breathing through their mouth because their nose is stuffy.
Because children do not always understand what allergies are or how they affect people, they sometimes put up with severe symptoms. This can really affect their life. Children with allergies can have trouble concentrating or doing school work. They can even have trouble with sports. Your child might not be able to tell you what is wrong, but you can look for symptoms that show up at the same time each year or last a long time. You might also be able to tell that a child has allergies by the way he or she looks (picture 1).
Seasonal allergy symptoms usually don’t show up in children until after age 2. If your child is younger than 2 and has these symptoms, talk to his or her doctor about what might be causing them.
Is there a test for seasonal allergies? — Yes. Your child’s doctor will ask about his or her symptoms and do an exam. He or she might order other tests, such as allergy skin testing. Skin testing can help the doctor figure out what your child is allergic to. During a skin test, a doctor will put a drop of the substance your child might be allergic to on his or her skin, and make a tiny prick in the skin. Then, he or she will watch your child’s skin to see if it turns red and bumpy.
How are seasonal allergies treated? — Children with seasonal allergies might get one or more of the following treatments to help reduce their symptoms:
●Nose rinses – Older children can try nose rinses. Rinsing out the nose with salt water cleans the inside of the nose and gets rid of pollen in the nose. This can also help to clear things out if the nose is very stuffed up. Different devices can be used to rinse the nose.
●Steroid nose sprays – Doctors often prescribe these sprays first, but it can take days to weeks before they work. (Steroid nose sprays do not contain the same steroids that athletes take to build muscle.) Your child’s doctor will prescribe the safest dose for his or her age. In the US, it’s also possible to get one steroid nose spray without a prescription. If you decide to use this on your child, check with your child’s doctor if your child needs it more than 2 months of the year. Use for longer than 2 months should be monitored by a doctor or nurse.
●Antihistamines – These medicines help stop itching, sneezing, and runny nose symptoms. Some antihistamines can make people feel tired, and should not be given to young children. Talk to your child’s doctor before trying any new medicines.
●Allergy shots – Your child’s doctor might suggest that he or she get allergy shots. Usually, allergy shots are given every week or month by an allergy doctor. These shots can help lower your child’s risk of getting asthma later in life.
If you want to try over-the-counter (nonprescription) medicines for your child, be sure to read the directions carefully. Some, like medicines used to treat a stuffy nose or red eyes, are not safe for young children.
Talk with your child’s doctor or nurse about the benefits and downsides of the different treatments. The right treatment for your child will depend a lot on his or her symptoms and other health problems. It is also important to talk with your child’s doctor or nurse about when and how your child should take certain medicines.
Can seasonal allergy symptoms be prevented? — Yes. If your child gets symptoms at the same time every year, talk with his or her doctor or nurse. Some people can prevent symptoms by starting their medicine a week or two before that time of the year.
You can also help prevent symptoms by having your child avoid the things he or she is allergic to. For example, if your child is allergic to pollen, you can:
●Keep your child inside during the times of the year when he or she has symptoms
●Keep car and house windows closed, and use air conditioning instead
●Have your child take a bath or shower before bed to rinse pollen off the hair and skin
●Use a vacuum with a special filter (called a “HEPA filter”) to keep indoor air as clean as possible
What is insomnia? — Insomnia is a problem with sleep. People with insomnia have trouble falling or staying asleep, or they do not feel rested when they wake up. Insomnia is not about the number of hours of sleep a person gets. Everyone needs a different amount of sleep.
What are the symptoms of insomnia? — People with insomnia often:
●Have trouble falling or staying asleep
●Feel tired or sleepy during the day
●Forget things or have trouble thinking clearly
●Get cranky, anxious, irritable, or depressed
●Have less energy or interest in doing things
●Make mistakes or get into accidents more often than normal
●Worry about their lack of sleep
These symptoms can be so bad that they affect a person’s relationships or work life. Plus, they can happen even in people who seem to be sleeping enough hours.
Are there tests I should have? — Probably not. Most people with insomnia need no tests. Your doctor or nurse will probably be able to tell what is wrong just by talking to you. He or she might also ask you to keep a daily log for 1 to 2 weeks, where you keep track of how you sleep each night
In some cases, people do need special sleep tests, such as “polysomnography” or “actigraphy.”
●Polysomnography – Polysomnography is a test that usually lasts all night and that is done in a sleep lab. During the test, monitors are attached to your body to record movement, brain activity, breathing, and other body functions.
●Actigraphy – Actigraphy records activity and movement with a monitor or motion detector that is usually worn on the wrist. The test is done at home, over several days and nights. It will record how much you actually sleep and when.
What can I do to improve my insomnia? — You can follow good “sleep hygiene.” That means that you:
●Sleep only long enough to feel rested and then get out of bed
●Go to bed and get up at the same time every day
●Do not try to force yourself to sleep. If you can't sleep, get out of bed and try again later.
●Have coffee, tea, and other foods that have caffeine only in the morning
●Avoid alcohol in the late afternoon, evening, and bedtime
●Avoid smoking, especially in the evening
●Keep your bedroom dark, cool, quiet, and free of reminders of work or other things that cause you stress
●Solve problems you have before you go to bed
●Exercise several days a week, but not right before bed
●Avoid looking at phones or reading devices (“e-books”) that give off light before bed. This can make it harder to fall asleep.
Other things that can improve sleep include:
●Relaxation therapy, in which you focus on relaxing all the muscles in your body 1 by 1
●Working with a counselor or psychologist to deal with the problems that might be causing poor sleep
Should I see a doctor or nurse? — Yes. If you have insomnia, and it is troubling you, see your doctor or nurse. He or she might have suggestions on how to fix the problem.
Are there medicines to help me sleep? — Yes, there are medicines to help with sleep. But you should try them only after you try the techniques described above. You also should not use sleep medicines every night for long periods of time. Otherwise, you can become dependent on them for sleep.
Insomnia is sometimes caused by mental health problems, such as depression or anxiety. If that's the case for you, you might benefit from an antidepressant rather than a sleep aid. Antidepressants often improve sleep and can help with other worries, too.
Can I use alcohol to help me sleep? — No, do not use alcohol as a sleep aid. Even though alcohol makes you sleepy at first, it disrupts sleep later in the night.
When should I call the doctor about my child’s sore throat? — Sore throat is a common problem in children. It usually gets better on its own. But sore throat can sometimes be serious.
Call your child’s doctor or nurse if your child has a sore throat and:
●Has a fever of at least 101°F or 38.4°C
●Doesn’t want to eat or drink anything
Call for an ambulance (in the US and Canada, dial 9-1-1) or take your child to the emergency room if your child:
●Has trouble breathing or swallowing
●Is drooling much more than usual
●Has a stiff or swollen neck
What causes sore throat? — Sore throat is usually caused by an infection. Two types of germs can cause the infection: viruses and bacteria. Children spread germs easily because they often touch each other, share toys, and put things in their mouths.
Children who have a sore throat caused by a virus do not usually need to see a doctor or nurse. Children who have a sore throat caused by bacteria might need to see a doctor or nurse. They might have a type of infection called strep throat
How can I tell if my child’s sore throat is caused by a virus or strep throat? — It is hard to tell the difference. But there are some clues to look for
People who have a sore throat caused by a virus usually have other symptoms, too. These can include:
●A runny nose
●A stuffed-up chest
●Itchy or red eyes
●A raspy (hoarse) voice
●Pain in the roof of the mouth
People who have strep throat DO NOT usually have a cough, runny nose, or itchy or red eyes.
If you think your child might have strep throat, call your child’s doctor. He or she can do a test to check for the bacteria that cause strep throat.
Does my child need antibiotics? — If the sore throat is caused by a virus, your child DOES NOT need antibiotics. Unless your child has strep throat, antibiotics will NOT help.
What can I do to help my child feel better? — There are several ways to help relieve a sore throat:
●Soothing foods and drinks – Give your child things that are easy to swallow, like tea or soup, or popsicles to suck on. Your child might not feel like eating or drinking, but it’s important that he or she gets enough liquids. Offer different warm and cold drinks for your child to try.
●Medicines – Acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin) can help with throat pain. The correct dose depends on your child’s weight, so ask your child’s doctor how much to give.
Do not give aspirin or medicines that contain aspirin to children younger than 18 years. In children, aspirin can cause a serious problem called Reye syndrome. Do not give children throat sprays or cough drops, either. Throat sprays and cough drops are no better at relieving throat pain than hard candies. Plus, throat sprays can cause an allergic reaction.
●Other treatments – For children who are older than 3 to 4 years, sucking on hard candies or a lollipop might help. For children older than 6 to 8 years, gargling with salt water might help.
When can my child go back to school? — If your child’s sore throat is caused by a virus, he or she should be able to go back to school as soon as he or she feels better. If your child has a fever, he or she should stay home for at least 24 hours after the fever has gone away.
How can I keep my child from getting a sore throat again? — Wash your child’s hands often with soap and water. It is one of the best ways to prevent the spread of infection. You can use an alcohol rub instead, but make sure the hand rub gets everywhere on your child’s hands.
Try to teach your child about other ways to avoid spreading germs, such as not touching his or her face after being around a sick person.
●Routine monitoring of symptoms and lung function
●Patient education to create a partnership between clinician and patient
●Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity
GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: reduction in impairment and reduction of risk .
Reduce impairment — Impairment refers to the intensity and frequency of asthma symptoms and the degree to which the patient is limited by these symptoms. Specific goals for reducing impairment include:
●Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)
●Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms
●Few night-time awakenings (<2 nights per month) due to asthma
●Optimization of lung function
●Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise
●Satisfaction with asthma care on the part of patients and families
Reduce risk — The 2007 NAEPP guidelines introduced the concept of risk to encompass the various adverse outcomes associated with asthma and its treatment . These include asthma exacerbations, suboptimal lung development (children), loss of lung function over time (adults), and adverse effects from asthma medications. Proper asthma management attempts to minimize the patient's likelihood of experiencing these outcomes. Specific goals for reducing risk include:
●Prevention of recurrent exacerbations and need for emergency department or hospital care
●Prevention of reduced lung growth in children, and loss of lung function in adults
●Optimization of pharmacotherapy with minimal or no adverse effects
MONITORING PATIENTS WITH ASTHMA — Currently, the majority of medical visits for asthma are for urgent care. Effective asthma management, however, requires a proactive, preventative approach, similar to the treatment of hypertension or diabetes. Routine follow-up visits for patients with active asthma are recommended, at a frequency of every one to six months, depending upon the severity of asthma. These visits should be used to assess multiple aspects of the patient's asthma . The aspects of the patient's asthma that should be assessed at each visit include the following: signs and symptoms, pulmonary function, quality of life, exacerbations, adherence with treatment, medication side effects, and patient satisfaction with care.
Well-controlled asthma is characterized by daytime symptoms no more than twice per week and nighttime symptoms no more than twice per month. SABAs for relief of asthma symptoms should be needed less often than twice weekly, and there should be no interference with normal activity (preventative use of a SABA, such as prior to exercise, is acceptable even if used in this way on a daily basis). Peak flow should remain normal or near-normal. Oral glucocorticoid courses and/orurgent care visits should be needed no more than once per year . Assessment of control in patients of different ages is summarized in the tables (table 1A-C).
Symptom assessment — Symptoms over the past two to four weeks should be assessed at each visit. Assessment should address daytime symptoms, nighttime symptoms, use of short acting inhaled beta agonists to relieve symptoms, and difficulty in performing normal activities and exercise. Several quick and validated questionnaires, like the Asthma Control Test, have been published (form 1 and figure 1) [5-15].
Assessment of impairment — The following questions are representative of those used in validated questionnaires to assess asthma control:
●Has your asthma awakened you at night or in the early morning?
●How often have you been needing to use your quick-acting relief medication to relieve symptoms of cough, shortness of breath, or chest tightness?
●Have you needed any unscheduled care for your asthma, including calling in, an office visit, or an emergency department visit?
●Have you been able to participate in school/workand recreational activities as desired?
●If you are measuring your peak flow, has it been lower than your personal best? Home monitoring of peak flow measurements is reviewed in detail separately. (See "Peak expiratory flow rate monitoring in asthma".)
●Have you had any side effects from your asthma medications?
Assessment of risk — The following questions address the most important risk factors for future exacerbations . A discussion of the risk factors for fatal and near-fatal asthma is provided separately. (See"Identifying patients at risk for fatal asthma", section on 'Identifying high-risk patients'.)
●Have you taken oral glucocorticoids ("steroids") for your asthma in the past year?
●Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?
●Have you been admitted to the intensive care unit or been intubated because of your asthma? If yes, did this occur within the past five years?
●Do you currently smoke cigarettes?
●Have you ever noticed an increase in asthma symptoms after taking aspirin or a nonsteroidal antiinflammatory agent (NSAID)?
Monitoring pulmonary function — Peak expiratory flow rate (PEFR) (performed in the office and/or at home) and spirometry (performed in the office) are the two most commonly employed modalities for monitoring pulmonary function in children older than five years of age and in adults. The 2007 NAEPP guidelines state a preference for use of spirometry in medical offices, when available . Children older than five years of age are usually able to perform the peak flow or spirometric maneuver.
It is now recognized that insomnia is often an independent disorder [2,3]. Insomnia may occur in the absence of coexisting conditions and, when coexisting conditions exist, may persist despite successful treatment of the coexisting condition. Treatment directed at the insomnia and the comorbidity may be necessary. Since insomnia can precipitate, exacerbate, or prolong comorbid conditions, treatment of insomnia may improve comorbidities [4-7].
Treatment of insomnia is described in this topic review. The definition, types, epidemiology, clinical features, consequences, and diagnostic evaluation of insomnia are reviewed elsewhere. (See "Overview of insomnia"and "Clinical features and diagnosis of insomnia".)
GENERAL APPROACH — All patients with insomnia should receive therapy for any medical condition, psychiatric illness, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia (table 1). They should also receive basic behavioral counseling about sleep hygiene (table 2) and stimulus control (table 3).
For patients who continue to have insomnia that is sufficiently burdensome to warrant other interventions, reasonable approaches include behavioral therapy, medication, or both:
●Behavioral therapies beyond sleep hygiene and stimulus control include relaxation, sleep restriction therapy, cognitive therapy, and cognitive behavioral therapy. These therapies are not available in all medical centers. (See 'Behavioral therapy' below.)
●Approved medications used to treat insomnia include benzodiazepines, nonbenzodiazepine sedatives, melatonin agonists, and antidepressants. (See 'Medications' below.)
●Combination therapy involves initially prescribing both cognitive behavioral therapy and a medication (usually for six to eight weeks), then tapering the medication off or to an as-needed schedule while continuing cognitive behavioral therapy. (See'Combination therapy' below.) The use of medication prior to the initiation of behavioral therapy appears to be less effective .