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For years, Sharad Acharya’s frequent hikes in the mountains outside http://blackcrows.co.uk/purchase-cialis-online/ Denver would leave him short can you purchase cialis over the counter of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven can you purchase cialis over the counter stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.“It’s part of my genetics, for sure,” he said.South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion can you purchase cialis over the counter people — they make up only a quarter of the planet’s population.In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

Email Sign-Up Subscribe to KHN’s free Morning can you purchase cialis over the counter Briefing. Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into can you purchase cialis over the counter heart disease among South Asian Americans and raising awareness of the issue.

The bill passed the U.S. House in September and is up for consideration in the Senate.The issue could gain more attention after Sen. Kamala Harris (D-Calif.) can you purchase cialis over the counter becomes the nation’s first vice president with South Asian lineage.

Harris’ mother, Shyamala Gopalan, moved from India to the U.S. In 1958 to attend can you purchase cialis over the counter graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans.

The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios can you purchase cialis over the counter. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.One of the nation’s largest undertakings to understand these risks is the Mediators can you purchase cialis over the counter of Atherosclerosis in South Asians Living in America study, which began in 2006.

The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress can you purchase cialis over the counter that high blood pressure and diabetes are common in the community, even for people at normal weights.That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.Another risk factor, this one cultural, is diet.

Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.“We have to understand the can you purchase cialis over the counter cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician.

€œThat means something totally different than … a Westerner who’s going to can you purchase cialis over the counter be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. €œOne of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.Acharya’s health is still an issue. He said he had to get four more stents this year, can you purchase cialis over the counter and the surgeries have put pressure on his family.

But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.(Eli Imadali for KHN)The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s can you purchase cialis over the counter leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.The center’s medical director, Dr.

César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the can you purchase cialis over the counter community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.Dr.

Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of erectile dysfunction treatment complications so should now especially work to improve their cardiovascular health and fitness.In Colorado, Acharya’s can you purchase cialis over the counter health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and can you purchase cialis over the counter once more exploring his beloved mountains.“Nowadays, I feel very, very good,” he said.

€œI’m hiking a lot.” Related Topics California States Chronic Disease Care ColoradoSANTA CRUZ, Calif. €” For Tom Davis, being told by the state this week that he must close his Pacific Edge Climbing Gym for the third time in six months is beyond frustrating can you purchase cialis over the counter. The first time the rock-climbing gym and fitness center shut down, co-owners Davis and Diane Russell took out a government loan to pay employees.

The second time, can you purchase cialis over the counter they were forced to lay everyone off — themselves included. Now, as they face another surge of erectile dysfunction treatment cases across California, he fears he may lose the business for good. California’s ping-ponging approach to managing the cialis — twice reopening large portions of the service-sector economy only to shut them again — doesn’t seem just or reasonable, Davis said.

As of Tuesday evening, he was planning to defy the order, keeping the can you purchase cialis over the counter gym open but with additional restrictions on capacity. €œThe government is essentially saying, ‘We’re just picking you to personally go bankrupt and all the people who work with you,’” said Davis. €œNobody can afford to live in Santa Cruz on unemployment.” It’s a grim time in can you purchase cialis over the counter the cialis.

California has surpassed 1 million cases of erectile dysfunction treatment and 94% of Californians — more than 37.7 million people — live in a county considered to have “widespread” . Santa Cruz is one of 41 California counties now under the most restrictive orders in the state’s four-tiered erectile dysfunction treatment blueprint for determining which businesses can stay open amid the cialis, and under can you purchase cialis over the counter what proscriptions. (Blueprint for a Safer Economy/erectile dysfunction treatment19.ca.gov) Until Monday, Santa Cruz was in the red tier — the second-most restrictive — meaning Pacific Edge could be open at 10% capacity.

Now, its owners are being told can you purchase cialis over the counter to close entirely. For business owners and workers, a backward slide on the blueprint represents yet another financial setback in a bleak year, leaving some residents angry, exasperated and wondering if this is really the best the state can do. It’s a question reverberating nationwide as every state experiences a deadly rise in erectile dysfunction treatment cases and a growing number of hospitals say they are simply out of beds.

Among states, California is performing relatively well, ranking 40th in cases can you purchase cialis over the counter per capita and 33rd in deaths, according to a New York Times tracker. But even here, the cialis is too pervasive in its spread — and the public health infrastructure too enfeebled — to make the reopening of businesses and schools an easy proposition. Some experts say that during a cialis, when can you purchase cialis over the counter the cialis is everywhere, the push and pull California businesses are enduring may be what success looks like in much of the U.S.

For months to come. €œThe yo-yo nature of this is a feature can you purchase cialis over the counter of the cialis,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University.

€œAnd in fact, when I look at really successful countries like South Korea, Taiwan and New Zealand, they all have a yo-yo feeling to them.” Experts say a crucial factor in being able to reopen can you purchase cialis over the counter safely is getting cases low enough that time-tested public health tools like quarantines and contact tracing can work. Most U.S. Hot spots, including broad swaths of California, have never achieved those low can you purchase cialis over the counter levels.

In California, Gov. Gavin Newsom, like many other governors, is trying to thread the needle, to keep cases to a minimum while also allowing many businesses to remain open. It’s a sensitive equation, said can you purchase cialis over the counter Dr.

Aimee Sisson, public health officer for Yolo County. €œIt’s really hard to dial in the balances of getting our economy going again, which is important for public health, and maintaining our health, which is can you purchase cialis over the counter important for the economy.” And while California is doing better than many other states, said Cameron Kaiser, the health officer for Riverside County, it’s certainly not cause for celebration. €œAt this point we’re clearly doing better, but our trends are not good either.

When you’re talking about the relative impact of different tragedies, I’m not sure you’d call that a success.” Even as it frustrates some residents, California’s tiered can you purchase cialis over the counter reopening system has won praise nationally. The system draws on three erectile dysfunction treatment metrics to guide restrictions. New cases can you purchase cialis over the counter per population.

The share of people tested for the erectile dysfunction who are positive. And, in larger counties, an equity measure to ensure cases are low across the county, including in high-risk communities. Under revised guidelines released this week, county tier assignments can change from week to week — and more than once a week if data indicates a can you purchase cialis over the counter county is losing ground.

€œWe think it’s a best practice nationally and globally,” said Dr. Tom Frieden, a former director can you purchase cialis over the counter of the Centers for Disease Control and Prevention. €œThis is not about closure — this is about adjusting what is open when.” Still, the state blueprint isn’t perfect, health officers say.

In its early stages, there were can you purchase cialis over the counter inconsistencies around which businesses could stay open. For example, nail salons were treated differently from hair salons, though the exposure conditions are fairly similar. The state has taken feedback, said Sisson, can you purchase cialis over the counter and tried to make improvements.

And perhaps the biggest weakness is how little data exists to determine which businesses present the greatest risks for exposure and transmission, said Sisson and other health officers. While restaurants and bars are broadly considered high-risk because people remove their masks while eating and drinking, not much is known about viral spread at places like gyms and movie theaters, where it’s possible to reduce occupancy and wear masks. That’s part of what frustrates Davis in can you purchase cialis over the counter Santa Cruz.

Pacific Edge has reduced occupancy to just 30 people in the sprawling old factory building and instituted a range of protective measures. €œCompare that can you purchase cialis over the counter to Costco. I honestly believe we are just as safe if not safer than other businesses,” Davis said.

Measuring California’s success in navigating the cialis depends on what your goal is, said Marm Kilpatrick, an infectious disease researcher at the University of California-Santa Cruz who can you purchase cialis over the counter has been advising local government and businesses, including Pacific Edge, on reopening. The state has prioritized both keeping businesses open and keeping cases down, which means neither can be done perfectly. Still, he’s not sure can you purchase cialis over the counter the whiplash of openings and closings is the best the state can do.

He worries the tiered system may inadvertently send the wrong signals. Again and again, public health officials have watched in dismay as residents whose counties move into less-restrictive tiers revert to socializing in large groups and shedding basic safety protocols like masks and social distancing — followed by a dangerous upsurge in s and hospitalizations can you purchase cialis over the counter. Dr.

Mark Ghaly, the state’s Health and Human Services secretary, has acknowledged as much, stressing that cases are linked to both social gatherings and businesses. Ultimately, he said on Monday, the state is taking a “dual approach” that includes changes to business practices, and asking individuals to be disciplined in wearing masks can you purchase cialis over the counter outside the home, regularly sanitizing hands, staying 6 feet apart, and socializing outdoors and in small gatherings. Meanwhile, the holiday season looms.

The most recent can you purchase cialis over the counter spike in cases directly correlates to Halloween, several health officers said, just as previous spikes were linked to Memorial Day, the Fourth of July and Labor Day. With Thanksgiving, Christmas and New Year’s on the horizon, officials wonder whether they might have to recommend a farther-reaching stay-at-home order to keep cases under control. €œI’m very worried about can you purchase cialis over the counter Thanksgiving,” said Dr.

Chris Farnitano, health officer for Contra Costa County. €œThe tradition of so many families is to get together with their extended families, and that means gatherings with groups of people, and that’s where the cialis wants to spread.” In addition, can you purchase cialis over the counter Farnitano said, given the realities of commerce and travel, what happens in other states affects California. €œHaving other states with the same restrictions would help California,” he said.

What’s really needed, several public health officials said, is a coordinated national message and strategy. €œI’m hoping can you purchase cialis over the counter we’re gonna have the new president come in and take the reins very firmly,” said Steffanie Strathdee, associate dean of global health at UC-San Diego. €œHe has the right people around him advising him.

But, by then, winter will be half over can you purchase cialis over the counter and we’re going to be facing 400,000 deaths. Digging ourselves out of that mess is going to take awhile.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Anna Maria can you purchase cialis over the counter Barry-Jester.

annab@kff.org, @annabarryjester Jenny Gold. jgold@kff.org, @JennyAGold Related Topics Contact Us Submit a Story TipJournalists from KHN and the Guardian have identified 1,396 can you purchase cialis over the counter workers who reportedly died of complications from erectile dysfunction treatment they contracted on the job. Reporters are working to confirm the cause of death and workplace conditions in each case.

They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.Explore the new interactive tool tracking can you purchase cialis over the counter those health worker deaths. More From This Series. Related Topics Health Industry erectile dysfunction treatment Doctors Investigation Lost On The Frontline Nursing HomesNurse Leslie McKamey has gotten used to the 16-hour shifts, to skipping lunch, to the nightly ritual of throwing all her clothes in the laundry and showering as soon as she walks through the door to avoid potentially infecting her children.

She’s even grown accustomed to triaging erectile dysfunction treatment patients, who often arrive at the emergency room can you purchase cialis over the counter so short of breath they struggle to describe their symptoms. Explore Our Database KHN and The Guardian are tracking health care workers who died from erectile dysfunction treatment and writing about their lives and what happened in their final days. But despite can you purchase cialis over the counter the trauma and exhaustion of the past eight months, she was shocked when North Dakota Gov.

Doug Burgum said last week that health care workers who test positive for the erectile dysfunction but do not display symptoms could still report to work. The order, in line with CDC guidance for mitigating staff shortages, would allow can you purchase cialis over the counter asymptomatic health workers who test positive to work only in erectile dysfunction treatment units, and treat patients who already have the cialis.But many feel the idea endangers the workers and their colleagues. It comes as North Dakota faces one of the worst outbreaks of erectile dysfunction treatment and grapples with health care staff shortages.“We’re worried about somebody dying, frankly, because we couldn’t get to them in time,” said McKamey, an emergency room registered nurse in Bismarck.According to data from the erectile dysfunction treatment Tracking Project, more than 9,400 North Dakotans tested positive for erectile dysfunction treatment last week alone.

About 1 in 12 North Dakota residents have been infected with can you purchase cialis over the counter the cialis. Nearly 1 in 1,000 have died. In early November, the North Dakota Department of Health reported that there were only 12 open ICU beds in the state.McKamey said Burgum’s order goes against everything she’s been taught as a nurse.“If hospital administrators start forcing erectile dysfunction treatment-positive staff to go to work, it’s going to be very scary.

We’re trained to do no harm, and asking erectile dysfunction treatment-positive, asymptomatic nurses to return to work is can you purchase cialis over the counter putting patients at risk. It’s putting fellow staff members at risk.” Email Sign-Up Subscribe to KHN’s free Morning Briefing. Nine months into the cialis, it’s clear health care workers already face increased risks can you purchase cialis over the counter.

Lost on the Frontline, a joint effort by The Guardian and KHN, is investigating the deaths of 1,375 health care workers who appear to have died of erectile dysfunction treatment since the start of the cialis. Nearly a third of those health care workers were nurses.McKamey described long shifts in an emergency room that has begun taking on patients overnight because other can you purchase cialis over the counter wards of the hospital did not have the capacity to admit them. Nurses pick up extra shifts to cover for colleagues who have gotten sick and take on multiple critical patients at once.It is a scene playing out in hospitals across the country, as the erectile dysfunction spreads unabated.

As of Monday, more than 11 million people in the United States had been infected with can you purchase cialis over the counter the cialis, with health officials reporting 180,000 new s in a single day. And the country is bracing for another milestone. It will soon surpass a quarter-million deaths can you purchase cialis over the counter from erectile dysfunction treatment.Health care workers are overwhelmed and exhausted.

According to a recent survey from the National Nurses United, more than 70% of hospital nurses said they were afraid of contracting erectile dysfunction treatment and 80% feared they might infect a family member. More than half said they struggled to sleep and 62 reported feeling stressed and anxious. Nearly 80% said they were forced to reuse single-use PPE, like N95 respirators.Inaction at the state and federal levels have left many health care workers feeling abandoned.

When Gov. Burgum issued the order that infected but asymptomatic nurses could report to work in erectile dysfunction treatment units, North Dakota had not implemented any kind of statewide mask mandate, despite expert guidance that such a measure could significantly reduce transmission of the cialis.Tessa Johnson is a registered nurse at a Bismarck nursing home and president of the North Dakota Nurses Association, which issued a statement last week denouncing Burgum’s order that infected nurses continue to work.She said the state could have done much more to ensure patients don’t become infected in the first place. €œWe’ve asked and asked and asked for a mask mandate, and that hasn’t happened,” she said Thursday.On Friday night, Burgum did an about-face and issued a mask mandate, ordering individuals to cover their faces when inside businesses, indoor public settings and outdoor public settings where physical distancing may be impossible.“Our doctors and nurses heroically working on the front lines need our help, and they need it now,” he said in a press statement.Still, Johnson said there’s a disconnect between what health care workers are experiencing inside North Dakota’s health facilities, and how the general population perceives the cialis.

And that even before Burgum’s comments, some of her colleagues felt they had to choose between taking all precautions and limited time off. €œOne of my closest friends, also a health care worker, said to me the other day, ‘There’s no way I will ever get tested unless I’m very sick, because I don’t want to use my paid leave.’”McKamey, the ER nurse, said she hasn’t had time to process the stress of the past several months. She’s focused on staying healthy, gearing up for what she anticipates will be a difficult winter and keeping her patients alive.

€œWe are willing to break our backs and work as hard as we physically can,” McKamey said. €œBut then to ask us to come in as a potential infectious source is just stunning.” Related Topics Public Health States erectile dysfunction treatment Lost On The Frontline North Dakota Nurses.

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The tragedy Sophie Delezio endured as a cialis ad child made national news. Now, in a monthly interview series with Body+Soul, she sits down with fellow survivors.Lauren Huxley was just 18 when a man broke into her Sydney home and brutally attacked her in 2005. She was beaten so badly that doctors gave her a 5 per cent cialis ad chance of survival. She remained on life support for 23 days.Lauren’s road to recovery was long and extensive – she endured nine major surgeries and had to learn how to walk, talk and eat again.Ultimately, her mind would wipe the horrific event entirely from her memory – and she now describes feeling almost as if the incident happened to someone else, or occurred within a dream she can’t recollect.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.As survivors of physical trauma, it’s a feeling we both have in common.

I first met Lauren several years ago and was blown away cialis ad by her strength, courage and resilience. Speaking to her, I quickly realised you don’t have to have the same disability or history to have experienced the same pain.Today, Lauren is living life to the full – never questioning why this happened or letting negativity take over.Because of her memory loss, her sister Simone assisted with answering some of the questions in our interview.At the request of Lauren and her family, the attacker’s name will not be included.What was your recovery process like?. Lauren. I had to take it slow and cialis ad not push myself. I never thought “Why me?.

€ There was no point. I kept positive for the cialis ad sake of myself and my family.Simone. When she was first learning how to walk again, they put her on a board and tilted her to get her blood pressure used to being upright. I remember the colour drained from her face. Then they got her on this big walker and it was so hard to watch – she was screaming, like she was in pain, but it was actually more to do with her cialis ad brain trying to retrain itself to do these simple tasks.

Later on, we would be worried about whatever surgery she was about to have, but she’d just say, “Don’t worry about me, I’ll be right!. €What have been some of the challenges?. Lauren. I definitely had low points in the early stages. The hardest was watching my hair grow back – it was so short and grew back so slowly.

I have a bald spot where [the attacker] pulled my hair out and it’s never really healed. Going through five years of operations and rehabilitation, I was just focusing on getting better, so I missed out on a lot.I lost quite a few years of my life – I’m 34 but feel like I’m 29. My friends are at different stages now. Some never really understood or they stayed around for the wrong reasons, wanting the spotlight but not being there for me once it was gone. I didn’t need that in my life.How can we affect change so that others don’t have to go through what you did?.

Simone. [We need] tougher sentences. A tougher criminal system. The man who attacked my sister had 26 convictions already – he was on bail and parole, and then committed this crime. He should never have been out.

If he was in jail this never would have happened. How many others are like him?. He qualifies for parole in eight years, which is terrifying.Lauren. We need to educate kids from a young age – with programs about violence against men and women, starting at school. And the government needs to teach kids self-defence – people shouldn’t have to go out of their way to get that education.Sixteen years on, what have you learnt about yourself throughout this journey?.

Lauren. You never realise how strong you and your family can be until an experience really tests you. Family is everything. All their love and support they’ve given me over the years... I don’t know where I would be without them.Time really does heal.

I’m so happy and grateful to be alive – and I’ll never take things for granted again. I’m here for a reason. I survived..

The tragedy Sophie Delezio endured as can you purchase cialis over the counter a child made national news. Now, in a monthly interview series with Body+Soul, she sits down with fellow survivors.Lauren Huxley was just 18 when a man broke into her Sydney home and brutally attacked her in 2005. She was beaten so badly that doctors gave her a 5 per cent chance of survival can you purchase cialis over the counter.

She remained on life support for 23 days.Lauren’s road to recovery was long and extensive – she endured nine major surgeries and had to learn how to walk, talk and eat again.Ultimately, her mind would wipe the horrific event entirely from her memory – and she now describes feeling almost as if the incident happened to someone else, or occurred within a dream she can’t recollect.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.As survivors of physical trauma, it’s a feeling we both have in common. I first met Lauren several years ago and was blown away by her can you purchase cialis over the counter strength, courage and resilience.

Speaking to her, I quickly realised you don’t have to have the same disability or history to have experienced the same pain.Today, Lauren is living life to the full – never questioning why this happened or letting negativity take over.Because of her memory loss, her sister Simone assisted with answering some of the questions in our interview.At the request of Lauren and her family, the attacker’s name will not be included.What was your recovery process like?. Lauren. I had to take it slow and not can you purchase cialis over the counter push myself.

I never thought “Why me?. € There was no point. I kept positive for the sake of myself can you purchase cialis over the counter and my family.Simone.

When she was first learning how to walk again, they put her on a board and tilted her to get her blood pressure used to being upright. I remember the colour drained from her face. Then they got her on this big can you purchase cialis over the counter walker and it was so hard to watch – she was screaming, like she was in pain, but it was actually more to do with her brain trying to retrain itself to do these simple tasks.

Later on, we would be worried about whatever surgery she was about to have, but she’d just say, “Don’t worry about me, I’ll be right!. €What have been some of the challenges?. Lauren.

I definitely had low points in the early stages. The hardest was watching my hair grow back – it was so short and grew back so slowly. I have a bald spot where [the attacker] pulled my hair out and it’s never really healed.

Going through five years of operations and rehabilitation, I was just focusing on getting better, so I missed out on a lot.I lost quite a few years of my life – I’m 34 but feel like I’m 29. My friends are at different stages now. Some never really understood or they stayed around for the wrong reasons, wanting the spotlight but not being there for me once it was gone.

I didn’t need that in my life.How can we affect change so that others don’t have to go through what you did?. Simone. [We need] tougher sentences.

A tougher criminal system. The man who attacked my sister had 26 convictions already – he was on bail and parole, and then committed this crime. He should never have been out.

If he was in jail this never would have happened. How many others are like him?. He qualifies for parole in eight years, which is terrifying.Lauren.

We need to educate kids from a young age – with programs about violence against men and women, starting at school. And the government needs to teach kids self-defence – people shouldn’t have to go out of their way to get that education.Sixteen years on, what have you learnt about yourself throughout this journey?. Lauren.

You never realise how strong you and your family can be until an experience really tests you. Family is everything. All their love and support they’ve given me over the years...

I don’t know where I would be without them.Time really does heal. I’m so happy and grateful to be alive – and I’ll never take things for granted again. I’m here for a reason.

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The General Medical Council’s (GMC) motto of ‘Working with doctors, working for patients’ is at the heart of the work we carry out to ensure Buy generic levitra online medical schools and cialis 20mg vs viagra 50mg postgraduate medical training is of the high standard that patients demand, and rightly deserve. However, we know delivering world-class healthcare is taking its toll on doctors and carrying out research into how we can ease the burden and find how burnout can be prevented is becoming a key focus of our work.While still delivering our important statutory functions of controlling access to the register and investigating when things go wrong, we are actively supporting professionals to maintain and improve standards of good medical practice. Additionally, there is a vast amount of work taking place behind the scenes at the GMC to adapt to the ever-evolving environment we cialis 20mg vs viagra 50mg are training doctors to work in.SHAPING TRAINING TO MEET THE NEEDS OF WORKFORCE AND PATIENTSThe UK population is continuously changing.

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How to cialis 2.5 mg http://www.ec-aschbach.ac-strasbourg.fr/2019/12/06/une-petite-recette-pour-preparer-noel/ cite this article:Singh O P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one of the highly publicized events cialis 2.5 mg in our country. Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, the media went into a frenzy as newspapers, news channels, and social media were cialis 2.5 mg full of stories providing minute details of the suicidal act.

Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor. All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and cialis 2.5 mg their private and personal details were freely and blatantly broadcast and discussed on electronic, print, and social media. We understand that media houses have their own need and duty to report and sensationalize news for increasing their visibility (aka TRP), but such reporting has huge impacts on the mental health of the vulnerable population.The impact of this was soon realized when many incidents of copycat suicide were reported from all over the country within a few days of the incident. Psychiatrists suddenly started getting distress calls from cialis 2.5 mg their patients in despair with increased suicidal ideation.

This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] The Press Council of cialis 2.5 mg India has adopted the guidelines of World Health Organization report on Preventing Suicide. A resource for media professionals, which came out with an advisory to be followed by media in reporting cases of suicide. It includes points forbidding them from putting stories in prominent positions and unduly repeating them, explicitly describing the method used, providing details about the site/location, using sensational headlines, or using photographs and video footage of the incident.[2] Unfortunately, the advisory seems to have little effect in the aftermath of celebrity suicides. Channels were full of speculations about the person's mental cialis 2.5 mg condition and illness and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for cialis 2.5 mg training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident. Many psychiatrists and mental health professionals were called by media houses to comment on the episode. Many psychiatrists were quoted, or “misquoted,” or “quoted out of context,” commenting on the cialis 2.5 mg life of a person whom they had never examined and had no “professional authority” to do so.

There were even stories with byline of a psychiatrist where the content provided was not only unscientific but also way beyond the expertise of a psychiatrist. These types of viewpoints perpetuate stigma, myths, and “misleading concepts” about psychiatry and cialis 2.5 mg are detrimental to the image of psychiatry in addition to doing harm and injustice to our patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but we have witnessed the same phenomenon at the time of presidential candidature of Donald Trump.Psychiatrists should be encouraged to interact with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the cialis 2.5 mg media” can be a double-edged sword, and we should know about the rules of engagements and boundaries of interactions. Methods and principles of interaction with media should form a part of our training curriculum.

Many professional societies have guidelines and resource books for interacting with media, and psychiatrists should familiarize themselves with these documents. The Press Council guideline is likely to cialis 2.5 mg prompt reporters to seek psychiatrists for their expert opinion. It is useful for them to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as help available.[5]It is about time that the Indian Psychiatric Society formulated its own guidelines laying down the broad principles and boundaries governing the interaction of Indian psychiatrists with the media. Till then, it is desirable to be guided by the following broad principles:It should be assumed that no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not cialis 2.5 mg comment on any person whom he has not examinedPsychiatrists should take any such opportunity to educate the public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict cialis 2.5 mg of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective cialis 2.5 mg modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment.

The dangerousness of ECT has been mainly cialis 2.5 mg attributed to its claimed ability to cause brain damage. This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look cialis 2.5 mg at this question specifically. Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods.

These include cialis 2.5 mg structural, functional, and metabolic neuroimaging. Body fluid biochemical marker studies. And follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review of literature and present evidence suggests cialis 2.5 mg that ECT has a demonstrable impact on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords.

Adverse effect, brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, cialis 2.5 mg Singh SM. Does electroconvulsive therapy cause brain damage. An update cialis 2.5 mg. Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al.

In the mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic cialis 2.5 mg patients, and finally animal ECS studies. The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time. Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage cialis 2.5 mg in the context of ECT should refer to death or degeneration of brain tissue, which results in the impairment of functioning of the brain. The importance of precisely defining brain damage shall become evident subsequently in this review.There are now many more tools available to investigate the structure and function of brain in health and illness. However, there are obvious ethical issues in designing human studies that are designed to answer this specific question.

Therefore, one must necessarily take recourse to cialis 2.5 mg indirect evidences available through studies that have been designed to answer other research questions. These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT. Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain how ECT acts rather than evidence of cialis 2.5 mg gross structural damage per se. However, put together, all these studies would enable us to answer our titular question to some satisfaction. [Table 1] cialis 2.5 mg and [Table 2] provide an overview of the evidence base in this area.

Structural and Functional Neuroimaging Studies Devanand et al. Reviewed 16 structural neuroimaging studies on the effect of ECT on the brain.[4] Of these, two were pneumoencephalography studies, nine were computed tomography (CT) scan studies, and five were magnetic resonance imaging (MRI) studies. However, most of these studies were retrospective in design, with neuroimaging being done in patients who had cialis 2.5 mg received ECT in the past. In the absence of baseline neuroimaging, it would be very difficult to attribute any structural brain changes to ECT. In addition, pneumoencephalography, CT scan, and even early 0.3 T MRI provided images with much cialis 2.5 mg lower spatial resolution than what is available today.

The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain. The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT cialis 2.5 mg neuroimaging in the first 24 h after ECT to better capture the acute changes. A single study by Coffey et al. Followed up the patients for a duration of 6 months and repeated neuroimaging again at 6 months in order to capture any long-term changes following ECT.[10]The most important conclusion which emerged from this early series of studies was that there cialis 2.5 mg was no evidence of cortical atrophy, change in ventricle size, or increase in white matter hyperintensities.[4] The next major conclusion was that there appeared to be an increase in the T1 and T2 relaxation time immediately following ECT, which returned to normal within 24 h.

This supported the theory that immediately following ECT, there appears to be a temporary breakdown of the blood–brain barrier, leading to water influx into the brain tissue.[11] The last significant observation by Coffey et al. In 1991 was that there was no significant temporal changes in the total volumes of the frontal lobes, temporal lobes, or cialis 2.5 mg amygdala–hippocampal complex.[10] This was, however, something which would later be refuted by high-resolution MRI studies. Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 when Nordanskog cialis 2.5 mg et al.

Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al. That there was no volume increase in any part of the brain following ECT.[10] This was quite an exciting finding cialis 2.5 mg and was followed by several similar studies. However, the perspective of these studies was quite different from the early studies. In contrast to the early studies looking for the evidence cialis 2.5 mg of ECT-related brain damage, the newer studies were focused more on elucidating the mechanism of action of ECT. Further on in 2014, Nordanskog et al.

In a follow-up study showed that though there was a significant increase in the volume of the hippocampus 1 week after a course of ECT, the hippocampal volume returned to the baseline after 6 months.[19] Two other studies in 2013 showed that in addition to the hippocampus, the amygdala also showed significant volume increase following ECT.[20],[21] A series of structural neuroimaging studies after that have expanded on these findings and as of now, gray matter volume increase following ECT has been demonstrated in the hippocampus, amygdala, anterior temporal pole, subgenual cortex,[21] right caudate nucleus, and the whole of the medial temporal lobe (MTL) consisting of the hippocampus, amygdala, insula, and the posterosuperior temporal cortex,[24] para hippocampi, right subgenual anterior cingulate gyrus, and right anterior cingulate gyrus,[25] left cerebellar area VIIa crus I,[29] putamen, caudate nucleus, and nucleus acumbens [31] and clusters of increased cortical thickness involving the temporal pole, middle and superior temporal cortex, insula, and inferior temporal cortex.[27] However, the most consistently reported and replicated finding has been the bilateral increase in the volume of the hippocampus and amygdala. In light of these findings, it has been tentatively suggested that ECT acts by inducing neuronal regeneration in the hippocampus – amygdala complex.[42],[43] However, there are certain cialis 2.5 mg inconsistencies to this hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 cialis 2.5 mg months.[19] This, however, was not associated with the relapse of depressive symptoms. Another area of significant confusion has been the correlation of hippocampal volume increase with improvement of depressive symptoms.

Though almost all studies demonstrate a significant increase in hippocampal volume following ECT, a majority of studies failed to demonstrate a correlation between symptom improvement and hippocampal volume increase.[19],[20],[22],[24],[28] However, a significant minority of volumetric studies have demonstrated correlation between increase in hippocampal and/or amygdala volume and improvement of symptoms.[21],[25],[30]Another set of studies have used diffusion tensor imaging, functional MRI (fMRI), anatomical connectome, and structural network analysis to study the effect of ECT on the brain. The first of cialis 2.5 mg these studies by Abbott et al. In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase cialis 2.5 mg in connectivity.[22] In a first of its kind DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus.

The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale cialis 2.5 mg anatomical networks of the human brain – connectomes, based on white matter fiber tractography. The authors found significant reorganization in the anatomical connections involving the limbic structure, temporal lobe, and frontal lobe. It was also found that connection changes between amygdala and para hippocampus correlated with reduction in depressive symptoms.[26] In 2016, Wolf et al. Used a source-based morphometry approach to study the structural networks in patients with depression and cialis 2.5 mg schizophrenia and the effect of ECT on the same. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population.

It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following ECT in patients with major depressive disorder and cialis 2.5 mg bipolar disorder. The authors initially selected 32 original articles from which six articles met the criteria for quantitative synthesis. The results showed significant increase in the volume of the right and left hippocampus following ECT. For the rest of the brain regions, the heterogeneity cialis 2.5 mg in protocols and imaging techniques did not permit a quantitative analysis, and the authors have resorted to a narrative review similar to the present one with similar conclusions.[44] Focusing exclusively on hippocampal volume change in ECT, Oltedal et al. In 2018 conducted a mega-analysis of 281 patients with major depressive disorder treated with ECT enrolled at ten different global sites of the Global ECT-MRI Research Collaboration.[45] Similar to previous studies, there was a significant increase in hippocampal volume bilaterally with a dose–response relationship with the number of ECTs administered.

Furthermore, bilateral (B/L) ECT was associated with an equal increase in volume in both right and left hippocampus, whereas cialis 2.5 mg right unilateral ECT was associated with greater volume increase in the right hippocampus. Finally, contrary to expectation, clinical improvement was found to be negatively correlated with hippocampal volume.Thus, a review of the current evidence amply demonstrates that from looking for ECT-related brain damage – and finding none, we have now moved ahead to looking for a mechanistic understanding of the effect of ECT. In this regard, it has been cialis 2.5 mg found that ECT does induce structural changes in the brain – a fact which has been seized upon by some to claim that ECT causes brain damage.[46] Such statements should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic cialis 2.5 mg Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals of different molecules. The crucial difference, however, is that while MRI maps the MR signals of water molecules, MRSI maps the MR signals generated by different metabolites – such as N-acetyl aspartate (NAA) and choline-containing compounds. However, the concentration of these metabolites is at least 10,000 times lower than water molecules and hence the signal strength generated cialis 2.5 mg would also be correspondingly lower. However, MRSI offers us the unique advantage of studying in vivo the change in the concentration of brain metabolites, which has been of great significance in fields such as psychiatry, neurology, and basic neuroscience research.[47]MRSI studies on ECT in patients with depression have focused largely on four metabolites in the human brain – NAA, choline-containing compounds (Cho) which include majorly cell membrane compounds such as glycerophosphocholine, phosphocholine and a miniscule contribution from acetylcholine, creatinine (Cr) and glutamine and glutamate together (Glx). NAA is located exclusively in the neurons, and is suggested to be a marker of neuronal viability and functionality.[48] Choline-containing compounds (Cho) mainly include the membrane compounds, and an increase in Cho would be suggestive of increased membrane turnover.

Cr serves as a cialis 2.5 mg marker of cellular energy metabolism, and its levels are usually expected to remain stable. The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT. Of these, three studies showed that there is no significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of cialis 2.5 mg these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite. However, a direct cialis 2.5 mg comparison between these studies is complicated chiefly due to the different ECT protocols, which has been used in these studies.

It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations. The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis. Thus, the authors warn that to conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their cialis 2.5 mg study. In 2017, Cano et al. Also demonstrated a significant reduction in NAA/Cr ratio cialis 2.5 mg in the hippocampus post ECT.

More significantly, the authors also showed a significant increase in Glx levels in the hippocampus following ECT, which was also associated with an increase in hippocampal volume.[40] To explain these three findings, the authors proposed that ECT produces a neuroinflammatory response in the hippocampus – likely mediated by Glx, which has been known to cause inflammation at higher concentrations, thereby accounting for the increase in hippocampal volume with a reduction in NAA concentration. The cause for the volume increase remains unclear – with the authors speculating that it might be due to neuronal swelling or due to angiogenesis. However, the same study and multiple other past studies [21],[25],[30] have demonstrated cialis 2.5 mg that hippocampal volume increase was correlated with clinical improvement following ECT. Thus, we are led to the hypothesis that the same mechanism which drives clinical improvement with ECT is also responsible for the cognitive impairment following ECT. Whether this is a purely neuroinflammatory response or a neuroplastic response cialis 2.5 mg or a neuroinflammatory response leading to some form of neuroplasticity is a critical question, which remains to be answered.[40]Studies which have analyzed NAA concentration change in other brain areas have also produced conflicting results.

The ACC is another area which has been studied in some detail utilizing the MRSI technique. In 2003, cialis 2.5 mg Pfleiderer et al. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT. This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al. In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and cialis 2.5 mg that these levels were significantly elevated following ECT.[37] This again is contested by Njau et al.

Who showed that NAA levels are significantly reduced following ECT in the left dorsal ACC.[39] A direct comparison of these three studies is complicated by the different ECT and imaging parameters used and hence, no firm conclusion can be made on this point at this stage. In addition to this, one study had demonstrated increased NAA levels in the amygdala following administration of ECT,[34] cialis 2.5 mg with a trend level increase in Cho levels, which again is suggestive of neurogenesis and/or neuroplasticity. A review of studies on the DLPFC reveals a similarly confusing picture with one study, each showing no change, reduction, and elevation of concentration of NAA following ECT.[35],[37],[39] Here, again, a direct comparison of the three studies is made difficult by the heterogeneous imaging and ECT protocols followed by them.A total of five studies have analyzed the concentration of choline-containing compounds (Cho) in patients undergoing ECT. Conceptually, an increase in Cho signals is indicative of increased membrane turnover, which is postulated to be associated with synaptogenesis, neurogenesis, and maturation of neurons.[31] Of these, two studies measured Cho concentration in the B/L hippocampus, with contrasting results. Ende et cialis 2.5 mg al.

In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al. In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been cialis 2.5 mg studied in the amygdala, ACC, and the DLPFC. However, none of these studies showed a significant increase or decrease in Cho levels before and after ECT in the respective brain regions studied. In addition, no significant difference was seen in the pre-ECT Cho levels of patients compared to healthy cialis 2.5 mg controls.[34],[36],[37]In review, we must admit that MRSI studies are still at a preliminary stage with significant heterogeneity in ECT protocols, patient population, and regions of the brain studied. At this stage, it is difficult to draw any firm conclusions except to acknowledge the fact that the more recent studies – Njau et al., 2017, Cano, 2017, and Jorgensen et al., 2015 – have shown decrease in NAA concentration and no increase in Cho levels [38],[39],[40] – as opposed to the earlier studies by Ende et al.[33] The view offered by the more recent studies is one of a neuroinflammatory models of action of ECT, probably driving neuroplasticity in the hippocampus.

This would offer a mechanistic understanding of both clinical response and the phenomenon of cognitive impairment associated with ECT. However, this conclusion is based on cialis 2.5 mg conjecture, and more work needs to be done in this area. Body Fluid Biochemical Marker Studies Another line of evidence for analyzing the effect of ECT on the human brain is the study of concentration of neurotrophins in the plasma or serum. Neurotrophins are cialis 2.5 mg small protein molecules which mediate neuronal survival and development. The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect.

It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent cialis 2.5 mg stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other limbic structures, which, in turn, mediates the therapeutic action of ECT. Cognitive Impairment Studies Cognitive impairment has always been the single-most important side effect associated with ECT.[55] Concerns regarding long-term cognitive impairment surfaced soon after the introduction of ECT and since then has grown to become one of the most controversial aspects of ECT.[56] Anti-ECT groups have frequently pointed out to cognitive impairment following ECT as evidence of ECT causing brain damage.[56] A meta-analysis by Semkovska and McLoughlin in 2010 is one of the most detailed studies which had attempted to settle this long-standing debate.[57] The authors reviewed 84 studies (2981 participants), which had used a combined total of 22 standardized neuropsychological tests assessing various cognitive functions before and after ECT in patients diagnosed with major depressive disorder. The different cognitive domains reviewed included processing speed, attention/working cialis 2.5 mg memory, verbal episodic memory, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration.

However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive domains even showed mild improvement compared to the cialis 2.5 mg baseline performance. It was also demonstrated that not a single cognitive domain showed persistence of impairment beyond 15 days after ECT.Memory impairment following ECT can be analyzed broadly under two conceptual schemes – one that classifies memory impairment as objective memory impairment and subjective memory impairment and the other that classifies it as impairment in anterograde memory versus impairment in retrograde memory. Objective memory can be roughly defined as the ability to retrieve stored information and can be measured by various standardized neuropsychological tests. Subjective memory or meta-memory, on the other hand, refers to the ability to make judgments about one's ability to retrieve stored information.[58] As described cialis 2.5 mg previously, it has been conclusively demonstrated that anterograde memory impairment does not persist beyond 2 weeks after ECT.[57] However, one of the major limitations of this meta-analysis was the lack of evidence on retrograde amnesia following ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia.

It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another area of concern are reports of subjective memory impairment cialis 2.5 mg following ECT. One of the pioneers of research into subjective memory impairment were Squire and Chace who published a series of studies in the 1970s demonstrating the adverse effect of bilateral ECT on subjective assessment of memory.[62],[63],[64],[65] However, most of the studies conducted post 1980 – from when sine-wave ECT was replaced by brief-pulse ECT report a general improvement in subjective memory assessments following ECT.[71] In addition, most of the recent studies have failed to find a significant association between measures of subjective and objective memory.[63],[66],[70],[72],[73],[74] It has also been shown that subjective memory impairment is strongly associated with the severity of depressive symptoms.[75] In light of these facts, the validity and value of measures of subjective memory impairment as a marker of cognitive impairment and brain damage following ECT have been questioned. However, concerns regarding subjective memory impairment and catastrophic retrograde amnesia continue to persist, with significant dissonance between the findings of different research groups and patient self-reports in various media.[57]Some studies reported the possibility of ECT being associated with the development of subsequent dementia.[76],[77] However, a recent large, well-controlled prospective Danish study found that the use of ECT was not associated with elevated incidence of dementia.[78] Conclusion Our titular question is whether ECT leads to brain damage, where damage indicates destruction or degeneration of nerves or nerve tracts in the brain, which leads to loss of function. This issue cialis 2.5 mg was last addressed by Devanand et al. In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail.

And, what these studies reveal is rather than damaging the brain, ECT has a neuromodulatory effect on cialis 2.5 mg the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this. These neuromodulatory changes have been localized to the hippocampus, amygdala, and cialis 2.5 mg certain other parts of the limbic system. How exactly these changes mediate the improvement of depressive symptoms is a question that remains unanswered. However, there is little by way of evidence from neuroimaging studies which indicates that ECT causes destruction or degeneration of neurons.

Though cognitive impairment studies do show that there is objective impairment of certain functions – particularly memory immediately after ECT, cialis 2.5 mg these impairments are transient with full recovery within a span of 2 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent cialis 2.5 mg neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives neurogenesis, thereby exerting a neuromodulatory effect. This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the cialis 2.5 mg ECT.

However, these cannot be construed as brain damage as is usually understood. Due to the relative scarcity of data that directly examines the question of whether ECT causes brain damage, it is not possible to conclusively answer this question. However, in light of enduring ECT survivor accounts, there is a need to design studies that specifically answer this question.Financial support and cialis 2.5 mg sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Payne NA, Prudic J. Electroconvulsive therapy cialis 2.5 mg.

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37.Merkl A, Schubert F, Quante A, Luborzewski A, Brakemeier EL, Grimm S, et al. Abnormal cingulate and prefrontal cortical neurochemistry in major depression after electroconvulsive therapy. Biol Psychiatry 2011;69:772-9. 38.Jorgensen A, Magnusson P, Hanson LG, Kirkegaard T, Benveniste H, Lee H, et al. Regional brain volumes, diffusivity, and metabolite changes after electroconvulsive therapy for severe depression.

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A cohort study. Lancet Psychiatry 2018;5:348-56. Correspondence Address:Dr. Shubh Mohan SinghDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_239_19 Tables [Table 1], [Table 2]No AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type. Research ArticleAffiliations:1. Department of Rehabilitation, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe 2.

3. UCSF Pulmonary Rehabilitation and Sleep Disorders Center 4. Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA, , Email. [email protected]Publication date:01 July 2020More about this publication?. The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research.

The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal. Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesNo AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type.

Research ArticleAffiliations:1. Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil 2. Center for Infectious Disease Epidemiology and Surveillance, National Institute of Public Health and the Environment, Bilthoven, The Netherlands, , Email. [email protected]Publication date:01 July 2020More about this publication?. The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research.

The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal. Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websites.

How to cite where can you buy cialis over the counter this can you purchase cialis over the counter article:Singh O P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one can you purchase cialis over the counter of the highly publicized events in our country. Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, the media can you purchase cialis over the counter went into a frenzy as newspapers, news channels, and social media were full of stories providing minute details of the suicidal act.

Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor. All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and their private and personal details were freely and blatantly broadcast and discussed on electronic, can you purchase cialis over the counter print, and social media. We understand that media houses have their own need and duty to report and sensationalize news for increasing their visibility (aka TRP), but such reporting has huge impacts on the mental health of the vulnerable population.The impact of this was soon realized when many incidents of copycat suicide were reported from all over the country within a few days of the incident. Psychiatrists suddenly started can you purchase cialis over the counter getting distress calls from their patients in despair with increased suicidal ideation.

This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) can you purchase cialis over the counter of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] The Press Council of India has adopted the guidelines of World Health Organization report on Preventing Suicide. A resource for media professionals, which came out with an advisory to be followed by media in reporting cases of suicide. It includes points forbidding them from putting stories in prominent positions and unduly repeating them, explicitly describing the method used, providing details about the site/location, using sensational headlines, or using photographs and video footage of the incident.[2] Unfortunately, the advisory seems to have little effect in the aftermath of celebrity suicides. Channels were full of speculations can you purchase cialis over the counter about the person's mental condition and illness and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics can you purchase cialis over the counter in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident. Many psychiatrists and mental health professionals were called by media houses to comment on the episode. Many psychiatrists were quoted, or “misquoted,” or “quoted out of context,” commenting on the can you purchase cialis over the counter life of a person whom they had never examined and had no “professional authority” to do so.

There were even stories with byline of a psychiatrist where the content provided was not only unscientific but also way beyond the expertise of a psychiatrist. These types of viewpoints perpetuate stigma, myths, and “misleading concepts” about psychiatry and are detrimental to the image of psychiatry in addition to doing harm and can you purchase cialis over the counter injustice to our patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but we have witnessed the same phenomenon at the time of presidential candidature of Donald Trump.Psychiatrists should be encouraged to interact with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the media” can be a double-edged sword, and we should know about the can you purchase cialis over the counter rules of engagements and boundaries of interactions. Methods and principles of interaction with media should form a part of our training curriculum.

Many professional societies have guidelines and resource books for interacting with media, and psychiatrists should familiarize themselves with these documents. The Press Council guideline is likely to can you purchase cialis over the counter prompt reporters to seek psychiatrists for their expert opinion. It is useful for them to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as help available.[5]It is about time that the Indian Psychiatric Society formulated its own guidelines laying down the broad principles and boundaries governing the interaction of Indian psychiatrists with the media. Till then, it is desirable to be guided by the following broad principles:It should be assumed that can you purchase cialis over the counter no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not comment on any person whom he has not examinedPsychiatrists should take any such opportunity to educate the public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of can you purchase cialis over the counter Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive can you purchase cialis over the counter therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment.

The dangerousness of ECT has been mainly can you purchase cialis over the counter attributed to its claimed ability to cause brain damage. This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this can you purchase cialis over the counter question specifically. Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods.

These include can you purchase cialis over the counter structural, functional, and metabolic neuroimaging. Body fluid biochemical marker studies. And follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review can you purchase cialis over the counter of literature and present evidence suggests that ECT has a demonstrable impact on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords.

Adverse effect, brain damage, electroconvulsive therapyHow to cite can you purchase cialis over the counter this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update can you purchase cialis over the counter. Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al.

In the can you purchase cialis over the counter mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic patients, and finally animal ECS studies. The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time. Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts can you purchase cialis over the counter within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage in the context of ECT should refer to death or degeneration of brain tissue, which results in the impairment of functioning of the brain. The importance of precisely defining brain damage shall become evident subsequently in this review.There are now many more tools available to investigate the structure and function of brain in health and illness. However, there are obvious ethical issues in designing human studies that are designed to answer this specific question.

Therefore, one must can you purchase cialis over the counter necessarily take recourse to indirect evidences available through studies that have been designed to answer other research questions. These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT. Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain can you purchase cialis over the counter how ECT acts rather than evidence of gross structural damage per se. However, put together, all these studies would enable us to answer our titular question to some satisfaction. [Table 1] can you purchase cialis over the counter and [Table 2] provide an overview of the evidence base in this area.

Structural and Functional Neuroimaging Studies Devanand et al. Reviewed 16 structural neuroimaging studies on the effect of ECT on the brain.[4] Of these, two were pneumoencephalography studies, nine were computed tomography (CT) scan studies, and five were magnetic resonance imaging (MRI) studies. However, most of these studies were retrospective in design, with neuroimaging being done in patients who had can you purchase cialis over the counter received ECT in the past. In the absence of baseline neuroimaging, it would be very difficult to attribute any structural brain changes to ECT. In addition, can you purchase cialis over the counter pneumoencephalography, CT scan, and even early 0.3 T MRI provided images with much lower spatial resolution than what is available today.

The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain. The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While can you purchase cialis over the counter most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT neuroimaging in the first 24 h after ECT to better capture the acute changes. A single study by Coffey et al. Followed up the patients for a duration of 6 months and repeated neuroimaging again at 6 months in order to capture any long-term can you purchase cialis over the counter changes following ECT.[10]The most important conclusion which emerged from this early series of studies was that there was no evidence of cortical atrophy, change in ventricle size, or increase in white matter hyperintensities.[4] The next major conclusion was that there appeared to be an increase in the T1 and T2 relaxation time immediately following ECT, which returned to normal within 24 h.

This supported the theory that immediately following ECT, there appears to be a temporary breakdown of the blood–brain barrier, leading to water influx into the brain tissue.[11] The last significant observation by Coffey et al. In 1991 was that there was no significant temporal changes in the total can you purchase cialis over the counter volumes of the frontal lobes, temporal lobes, or amygdala–hippocampal complex.[10] This was, however, something which would later be refuted by high-resolution MRI studies. Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 can you purchase cialis over the counter when Nordanskog et al.

Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al. That there was no volume increase in any part of the brain following can you purchase cialis over the counter ECT.[10] This was quite an exciting finding and was followed by several similar studies. However, the perspective of these studies was quite different from the early studies. In contrast to the early studies looking for the evidence of ECT-related can you purchase cialis over the counter brain damage, the newer studies were focused more on elucidating the mechanism of action of ECT. Further on in 2014, Nordanskog et al.

In a follow-up study showed that though there was a significant increase in the volume of the hippocampus 1 week after a course of ECT, the hippocampal volume returned to the baseline after 6 months.[19] Two other studies in 2013 showed that in addition to the hippocampus, the amygdala also showed significant volume increase following ECT.[20],[21] A series of structural neuroimaging studies after that have expanded on these findings and as of now, gray matter volume increase following ECT has been demonstrated in the hippocampus, amygdala, anterior temporal pole, subgenual cortex,[21] right caudate nucleus, and the whole of the medial temporal lobe (MTL) consisting of the hippocampus, amygdala, insula, and the posterosuperior temporal cortex,[24] para hippocampi, right subgenual anterior cingulate gyrus, and right anterior cingulate gyrus,[25] left cerebellar area VIIa crus I,[29] putamen, caudate nucleus, and nucleus acumbens [31] and clusters of increased cortical thickness involving the temporal pole, middle and superior temporal cortex, insula, and inferior temporal cortex.[27] However, the most consistently reported and replicated finding has been the bilateral increase in the volume of the hippocampus and amygdala. In light of these findings, it has been tentatively suggested that ECT acts by inducing neuronal regeneration in the hippocampus – amygdala can you purchase cialis over the counter complex.[42],[43] However, there are certain inconsistencies to this hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 months.[19] This, however, was not associated with can you purchase cialis over the counter the relapse of depressive symptoms. Another area of significant confusion has been the correlation of hippocampal volume increase with improvement of depressive symptoms.

Though almost all studies demonstrate a significant increase in hippocampal volume following ECT, a majority of studies failed to demonstrate a correlation between symptom improvement and hippocampal volume increase.[19],[20],[22],[24],[28] However, a significant minority of volumetric studies have demonstrated correlation between increase in hippocampal and/or amygdala volume and improvement of symptoms.[21],[25],[30]Another set of studies have used diffusion tensor imaging, functional MRI (fMRI), anatomical connectome, and structural network analysis to study the effect of ECT on the brain. The first can you purchase cialis over the counter of these studies by Abbott et al. In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase in connectivity.[22] In a first of its kind can you purchase cialis over the counter DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus.

The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale can you purchase cialis over the counter anatomical networks of the human brain – connectomes, based on white matter fiber tractography. The authors found significant reorganization in the anatomical connections involving the limbic structure, temporal lobe, and frontal lobe. It was also found that connection changes between amygdala and para hippocampus correlated with reduction in depressive symptoms.[26] In 2016, Wolf et al. Used a source-based morphometry approach to study the structural networks in patients with can you purchase cialis over the counter depression and schizophrenia and the effect of ECT on the same. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population.

It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following can you purchase cialis over the counter ECT in patients with major depressive disorder and bipolar disorder. The authors initially selected 32 original articles from which six articles met the criteria for quantitative synthesis. The results showed significant increase in the volume of the right and left hippocampus following ECT. For the rest of the brain regions, the heterogeneity in protocols and imaging techniques did can you purchase cialis over the counter not permit a quantitative analysis, and the authors have resorted to a narrative review similar to the present one with similar conclusions.[44] Focusing exclusively on hippocampal volume change in ECT, Oltedal et al. In 2018 conducted a mega-analysis of 281 patients with major depressive disorder treated with ECT enrolled at ten different global sites of the Global ECT-MRI Research Collaboration.[45] Similar to previous studies, there was a significant increase in hippocampal volume bilaterally with a dose–response relationship with the number of ECTs administered.

Furthermore, bilateral (B/L) ECT was associated with can you purchase cialis over the counter an equal increase in volume in both right and left hippocampus, whereas right unilateral ECT was associated with greater volume increase in the right hippocampus. Finally, contrary to expectation, clinical improvement was found to be negatively correlated with hippocampal volume.Thus, a review of the current evidence amply demonstrates that from looking for ECT-related brain damage – and finding none, we have now moved ahead to looking for a mechanistic understanding of the effect of ECT. In this regard, it has been found that ECT does induce structural changes in the brain – a fact which has been seized can you purchase cialis over the counter upon by some to claim that ECT causes brain damage.[46] Such statements should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals can you purchase cialis over the counter of different molecules. The crucial difference, however, is that while MRI maps the MR signals of water molecules, MRSI maps the MR signals generated by different metabolites – such as N-acetyl aspartate (NAA) and choline-containing compounds. However, the concentration of these metabolites is at least can you purchase cialis over the counter 10,000 times lower than water molecules and hence the signal strength generated would also be correspondingly lower. However, MRSI offers us the unique advantage of studying in vivo the change in the concentration of brain metabolites, which has been of great significance in fields such as psychiatry, neurology, and basic neuroscience research.[47]MRSI studies on ECT in patients with depression have focused largely on four metabolites in the human brain – NAA, choline-containing compounds (Cho) which include majorly cell membrane compounds such as glycerophosphocholine, phosphocholine and a miniscule contribution from acetylcholine, creatinine (Cr) and glutamine and glutamate together (Glx). NAA is located exclusively in the neurons, and is suggested to be a marker of neuronal viability and functionality.[48] Choline-containing compounds (Cho) mainly include the membrane compounds, and an increase in Cho would be suggestive of increased membrane turnover.

Cr serves as a marker of cellular energy metabolism, and can you purchase cialis over the counter its levels are usually expected to remain stable. The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT. Of these, three studies showed that there is no can you purchase cialis over the counter significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite. However, a direct comparison between these studies is complicated chiefly due to the different can you purchase cialis over the counter ECT protocols, which has been used in these studies.

It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations. The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis. Thus, the authors warn that to can you purchase cialis over the counter conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated a can you purchase cialis over the counter significant reduction in NAA/Cr ratio in the hippocampus post ECT.

More significantly, the authors also showed a significant increase in Glx levels in the hippocampus following ECT, which was also associated with an increase in hippocampal volume.[40] To explain these three findings, the authors proposed that ECT produces a neuroinflammatory response in the hippocampus – likely mediated by Glx, which has been known to cause inflammation at higher concentrations, thereby accounting for the increase in hippocampal volume with a reduction in NAA concentration. The cause for the volume increase remains unclear – with the authors speculating that it might be due to neuronal swelling or due to angiogenesis. However, the same study and multiple other past studies [21],[25],[30] have demonstrated can you purchase cialis over the counter that hippocampal volume increase was correlated with clinical improvement following ECT. Thus, we are led to the hypothesis that the same mechanism which drives clinical improvement with ECT is also responsible for the cognitive impairment following ECT. Whether this is a purely neuroinflammatory response or a neuroplastic response or a neuroinflammatory response leading to some form of neuroplasticity is a critical question, which remains to be answered.[40]Studies which can you purchase cialis over the counter have analyzed NAA concentration change in other brain areas have also produced conflicting results.

The ACC is another area which has been studied in some detail utilizing the MRSI technique. In 2003, Pfleiderer et al can you purchase cialis over the counter. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT. This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al. In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and can you purchase cialis over the counter that these levels were significantly elevated following ECT.[37] This again is contested by Njau et al.

Who showed that NAA levels are significantly reduced following ECT in the left dorsal ACC.[39] A direct comparison of these three studies is complicated by the different ECT and imaging parameters used and hence, no firm conclusion can be made on this point at this stage. In addition to this, one study can you purchase cialis over the counter had demonstrated increased NAA levels in the amygdala following administration of ECT,[34] with a trend level increase in Cho levels, which again is suggestive of neurogenesis and/or neuroplasticity. A review of studies on the DLPFC reveals a similarly confusing picture with one study, each showing no change, reduction, and elevation of concentration of NAA following ECT.[35],[37],[39] Here, again, a direct comparison of the three studies is made difficult by the heterogeneous imaging and ECT protocols followed by them.A total of five studies have analyzed the concentration of choline-containing compounds (Cho) in patients undergoing ECT. Conceptually, an increase in Cho signals is indicative of increased membrane turnover, which is postulated to be associated with synaptogenesis, neurogenesis, and maturation of neurons.[31] Of these, two studies measured Cho concentration in the B/L hippocampus, with contrasting results. Ende et can you purchase cialis over the counter al.

In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al. In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been studied in the amygdala, ACC, and the can you purchase cialis over the counter DLPFC. However, none of these studies showed a significant increase or decrease in Cho levels before and after ECT in the respective brain regions studied. In addition, no significant difference was seen in the pre-ECT Cho levels of patients compared to healthy controls.[34],[36],[37]In review, we must admit can you purchase cialis over the counter that MRSI studies are still at a preliminary stage with significant heterogeneity in ECT protocols, patient population, and regions of the brain studied. At this stage, it is difficult to draw any firm conclusions except to acknowledge the fact that the more recent studies – Njau et al., 2017, Cano, 2017, and Jorgensen et al., 2015 – have shown decrease in NAA concentration and no increase in Cho levels [38],[39],[40] – as opposed to the earlier studies by Ende et al.[33] The view offered by the more recent studies is one of a neuroinflammatory models of action of ECT, probably driving neuroplasticity in the hippocampus.

This would offer a mechanistic understanding of both clinical response and the phenomenon of cognitive impairment associated with ECT. However, this conclusion is based can you purchase cialis over the counter on conjecture, and more work needs to be done in this area. Body Fluid Biochemical Marker Studies Another line of evidence for analyzing the effect of ECT on the human brain is the study of concentration of neurotrophins in the plasma or serum. Neurotrophins are small can you purchase cialis over the counter protein molecules which mediate neuronal survival and development. The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect.

It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other can you purchase cialis over the counter limbic structures, which, in turn, mediates the therapeutic action of ECT. Cognitive Impairment Studies Cognitive impairment has always been the single-most important side effect associated with ECT.[55] Concerns regarding long-term cognitive impairment surfaced soon after the introduction of ECT and since then has grown to become one of the most controversial aspects of ECT.[56] Anti-ECT groups have frequently pointed out to cognitive impairment following ECT as evidence of ECT causing brain damage.[56] A meta-analysis by Semkovska and McLoughlin in 2010 is one of the most detailed studies which had attempted to settle this long-standing debate.[57] The authors reviewed 84 studies (2981 participants), which had used a combined total of 22 standardized neuropsychological tests assessing various cognitive functions before and after ECT in patients diagnosed with major depressive disorder. The different cognitive domains can you purchase cialis over the counter reviewed included processing speed, attention/working memory, verbal episodic memory, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration.

However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive can you purchase cialis over the counter domains even showed mild improvement compared to the baseline performance. It was also demonstrated that not a single cognitive domain showed persistence of impairment beyond 15 days after ECT.Memory impairment following ECT can be analyzed broadly under two conceptual schemes – one that classifies memory impairment as objective memory impairment and subjective memory impairment and the other that classifies it as impairment in anterograde memory versus impairment in retrograde memory. Objective memory can be roughly defined as the ability to retrieve stored information and can be measured by various standardized neuropsychological tests. Subjective memory or meta-memory, on the other hand, refers to the ability to make judgments about can you purchase cialis over the counter one's ability to retrieve stored information.[58] As described previously, it has been conclusively demonstrated that anterograde memory impairment does not persist beyond 2 weeks after ECT.[57] However, one of the major limitations of this meta-analysis was the lack of evidence on retrograde amnesia following ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia.

It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another can you purchase cialis over the counter area of concern are reports of subjective memory impairment following ECT. One of the pioneers of research into subjective memory impairment were Squire and Chace who published a series of studies in the 1970s demonstrating the adverse effect of bilateral ECT on subjective assessment of memory.[62],[63],[64],[65] However, most of the studies conducted post 1980 – from when sine-wave ECT was replaced by brief-pulse ECT report a general improvement in subjective memory assessments following ECT.[71] In addition, most of the recent studies have failed to find a significant association between measures of subjective and objective memory.[63],[66],[70],[72],[73],[74] It has also been shown that subjective memory impairment is strongly associated with the severity of depressive symptoms.[75] In light of these facts, the validity and value of measures of subjective memory impairment as a marker of cognitive impairment and brain damage following ECT have been questioned. However, concerns regarding subjective memory impairment and catastrophic retrograde amnesia continue to persist, with significant dissonance between the findings of different research groups and patient self-reports in various media.[57]Some studies reported the possibility of ECT being associated with the development of subsequent dementia.[76],[77] However, a recent large, well-controlled prospective Danish study found that the use of ECT was not associated with elevated incidence of dementia.[78] Conclusion Our titular question is whether ECT leads to brain damage, where damage indicates destruction or degeneration of nerves or nerve tracts in the brain, which leads to loss of function. This issue was last addressed can you purchase cialis over the counter by Devanand et al. In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail.

And, what these studies reveal is can you purchase cialis over the counter rather than damaging the brain, ECT has a neuromodulatory effect on the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this. These neuromodulatory changes have been localized to the hippocampus, amygdala, and certain other can you purchase cialis over the counter parts of the limbic system. How exactly these changes mediate the improvement of depressive symptoms is a question that remains unanswered. However, there is little by way of evidence from neuroimaging studies which indicates that ECT causes destruction or degeneration of neurons.

Though cognitive impairment studies do can you purchase cialis over the counter show that there is objective impairment of certain functions – particularly memory immediately after ECT, these impairments are transient with full recovery within a span of 2 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives can you purchase cialis over the counter neurogenesis, thereby exerting a neuromodulatory effect. This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review can you purchase cialis over the counter of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the ECT.

However, these cannot be construed as brain damage as is usually understood. Due to the relative scarcity of data that directly examines the question of whether ECT causes brain damage, it is not possible to conclusively answer this question. However, in light of enduring ECT survivor accounts, there is a need to design can you purchase cialis over the counter studies that specifically answer this question.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Payne NA, Prudic J. Electroconvulsive therapy can you purchase cialis over the counter.

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A cohort study. Lancet Psychiatry 2018;5:348-56. Correspondence Address:Dr. Shubh Mohan SinghDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_239_19 Tables [Table 1], [Table 2]No AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type. Research ArticleAffiliations:1. Department of Rehabilitation, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe 2.

3. UCSF Pulmonary Rehabilitation and Sleep Disorders Center 4. Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA, , Email. [email protected]Publication date:01 July 2020More about this publication?. The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research.

The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal. Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesNo AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type.

Research ArticleAffiliations:1. Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil 2. Center for Infectious Disease Epidemiology and Surveillance, National Institute of Public Health and the Environment, Bilthoven, The Netherlands, , Email. [email protected]Publication date:01 July 2020More about this publication?. The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research.

The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal. Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websites.

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