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In this edition President Biden’s American Recovery Plan calls for additional premium subsidies and COBRA subsidiesNewly inaugurated President Joe Biden outlined his American Recovery Plan last week, and it includes some important click this over here now provisions can u buy viagra over the counter aimed at improving access to health coverage. The wide-ranging $1.9 trillion proposal, which would have to be approved by Congress, calls for premium tax credits to be increased “to lower or can u buy viagra over the counter eliminate health insurance premiums” and to cap any enrollee’s after-subsidy premium at no more than 8.5 percent of their income. This second provision would primarily help people with income near or a little above 400 percent of the poverty level, and could make a substantial difference in the affordability of coverage for some households that currently have to pay full-price for their coverage — sometimes amounting to well over a quarter of their income.The plan also calls for government subsidies of COBRA premiums through the end of September 2021. In 2009, the American Recovery and Reinvestment Act provided COBRA subsidies, which could serve as a model for how a new round can u buy viagra over the counter of COBRA subsidies might work.Biden’s American Recovery Plan encompasses far more than just health coverage. But if you’re curious about how health care reform might proceed under the new administration and the new Congress, check out this two-part series from Andrew Sprung, this piece from Charles Gaba, and can u buy viagra over the counter this piece from Katie Keith.Open enrollment ends Saturday in Massachusetts and Rhode IslandOpen enrollment for 2021 health coverage is still ongoing in five states and Washington, DC (plus a erectile dysfunction treatment-related special enrollment period for uninsured residents in Maryland).

But the enrollment window ends this Saturday, January 23, in Massachusetts and Rhode Island. After Saturday, residents in those states will need a qualifying event in order to enroll or make changes to their 2021 coverage.As of this week, confirmed marketplace enrollment totals for 2021 coverage have surpassed 11.6 million nationwide.Partial can u buy viagra over the counter 2022 health insurance rules finalized by outgoing Trump administrationLast fall, the Trump administration published the proposed Notice of Benefit and Payment Parameters for 2022. This annual rulemaking document is wide-ranging and typically addresses a variety can u buy viagra over the counter of issues related to the health insurance exchanges, special enrollment periods, risk adjustment, etc. At the time, we summarized several of the proposed rule changes that were most likely to directly affect people with individual market health plans.Last week, the Trump administration announced that it was finalizing some aspects of the proposal — including the most controversial ones — but that the rest of the proposed rule changes would be finalized in an additional rule that will be issued “at a later date.” That will be under the Biden administration, which is also likely to delay the rule the Trump administration finalized last week (currently slated to take effect March 15) and reissue a new proposed rule, with a new comment period.A total of 542 comments were submitted to CMS regarding the proposed rule changes for 2022. The comments that pertain can u buy viagra over the counter to the rule changes that CMS finalized last week are summarized in the final rule, along with the responses from CMS.

Notably:Although CMS noted that “nearly all commenters on this rulemaking cautioned about potential harmful impacts to consumers” of allowing states to abandon can u buy viagra over the counter their exchanges and rely entirely on brokers, agents, and insurers for health plan enrollment, the proposed rule change that would allow this was finalized. There would still be a role for an official exchange website in states that choose this option, but it would be minimal. And there are ongoing concerns that a switch to relying on brokers, agents, and insurers, instead of exchanges, will make it harder for Medicaid-eligible enrollees to understand the assistance and coverage that’s can u buy viagra over the counter available to them.The Trump administration’s 2018 guidance on 1332 waivers, which sharply relaxed the “guardrails” that apply to these waivers, is being officially incorporated into federal regulations.The fee that insurers pay HealthCare.gov (and pass on to consumers via premiums) will be reduced in 2022. In states that rely fully on HealthCare.gov, it will can u buy viagra over the counter be 2.25 percent of premiums. In states that run their own exchanges but use HealthCare.gov for enrollment, it will be 1.75 percent of premiums (down from a current 3 percent and 2.5 percent, respectively).Many of the proposed rule changes are still under consideration and were not finalized last week, including the premium adjustment percentage (which would affect maximum out-of-pocket amounts and the affordability threshold for catastrophic plan eligibility), special enrollment periods when employer COBRA subsidies cease or a person loses eligibility for premium subsidies, and a rule change that would permanently allow insurers to issue MLR rebates earlier in the year.At Health Affairs, Katie Keith has an excellent in-depth analysis of the partial final rule.Lawsuit filed to block Georgia’s plan to eliminate its health insurance exchangeLast fall, the Trump administration approved Georgia’s 1332 waiver proposal to transition away from HealthCare.gov and instead utilize a system that relies on brokers, agents, and insurers to get people enrolled, without a centralized exchange (the finalized rule change that allows a similar approach nationwide is very reminiscent of Georgia’s 1332 waiver).Last week, Planned Parenthood Southeast and Feminist Women’s Health Center filed a lawsuit against HHS, CMS, the Department of the Treasury, and their respective leaders, alleging that the waiver was unlawfully approved and should be vacated.

Democracy Forward, which is representing the plaintiffs in the case, explained that Georgia’s 1332 waiver “will do immense damage to Georgia’s health insurance market, can u buy viagra over the counter force Georgians to shop for insurance through private brokers and insurance companies, lead more residents to enroll in junk plans, and increase premiums.”Bills introduced in Virginia to eliminate state ban on abortion coverage under marketplace plans. Study impact of mandating coverage for infertilityVirginia is one of 26 states where health insurance plans sold in the marketplace/exchange are not allowed can u buy viagra over the counter to provide coverage for abortions. (Virginia’s ban includes exceptions for abortion coverage in cases of rape, incest, or the mother’s life being in danger.) Legislation was introduced last week in Virginia’s Senate that would eliminate this ban, allowing insurers to offer abortion coverage if they choose to do so.Legislation has also been introduced in Virginia that would direct the Virginia Health Insurance Reform Commission to conduct a study on the impacts of requiring health insurance plans in the state to cover infertility treatment. There are currently 19 states that mandate at least some coverage for infertility treatment.Legislation introduced in Maryland and Rhode Island to create universal healthcare commissionsLegislation was introduced in Maryland last week that calls for the state to create a can u buy viagra over the counter Commission on Universal Health Care. The Commission would be tasked with developing a plan for the state to establish a single-payer universal coverage system by 2024.Legislation was also introduced in Rhode Island last week that calls for the creation of a special legislative commission that would study how the state might go about implementing a single-payer Medicare-for-All type of health coverage program in Rhode Island.Legislation introduced in Missouri to create a Medicaid work requirementMissouri has not yet expanded Medicaid can u buy viagra over the counter eligibility under the ACA, but that will change this summer, thanks to a ballot initiative that voters in the state passed last year.

Legislation was introduced this month in Missouri’s Senate that calls for a Medicaid work requirement in the state, effective as of January 2022. Under the terms of the bill, non-exempt Medicaid enrollees would have to work (or participate in can u buy viagra over the counter various other community engagement activities, including volunteering, school, job training, etc.) at least 80 hours per week in order to maintain eligibility for Medicaid.The Trump administration approved numerous work requirement waivers over the last few years, but due to lawsuits and the erectile dysfunction treatment viagra, none are currently in effect. And the Biden administration is very unlikely to approve any additional waivers, meaning that Missouri’s legislation is likely a non-starter for the time being, even if it’s enacted.Uncompensated care funding in Florida and Texas extended through 2030Last Friday, the Trump administration renewed 1115 waivers in Texas and Florida, both of which are now valid can u buy viagra over the counter through mid-2030. These waivers are for Medicaid managed care, and also provide federal funding for uncompensated care – which is more of a problem in states like Texas and Florida, due to their failure to expand Medicaid and the resulting coverage gap for low-income residents.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about can u buy viagra over the counter the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited can u buy viagra over the counter by media who cover health reform and by other health insurance experts.In this edition Open enrollment for 2021 health plans will end in five states on FridayOpen enrollment for individual/family health plans ended a month ago in most of the country, but it’s still underway in ten states and Washington, DC. In five of those states, there are only a few days left. Open enrollment can u buy viagra over the counter ends this Friday, January 15, in five states. Residents in those states can currently enroll can u buy viagra over the counter in a plan with a February 1 start date. But after Friday, enrollment in those states will only be possible for people who experience a qualifying event (and most qualifying events require that the person already had minimum essential coverage within the prior 60 days).Exchange enrollment has already surpassed last year’s totalAs of January 12, confirmed enrollment in individual market plans via the exchanges stood at 11.5 million, according to Charles Gaba of ACA Signups.

And open can u buy viagra over the counter enrollment is still ongoing in ten states and Washington, DC (plus a special enrollment period for uninsured Maryland residents). What’s more, four states – Idaho, New York, Rhode Island, and Vermont – haven’t yet reported any of their enrollment data for 2021 plans.Last year, when all was said and done, enrollment reached 11.4 million, so it’s already surpassed the 2020 total can u buy viagra over the counter – the first time since 2016 that year-over-year enrollment has grown during the open enrollment period. Once open enrollment closes in all states and final data are reported, Gaba projects that this year’s enrollment will exceed 12 million.HHS extends erectile dysfunction treatment public health emergency through mid-AprilLast week, HHS Secretary Alex Azar announced that the erectile dysfunction treatment public health emergency was being extended for another 90 days, through April 21, 2021. The ongoing public health emergency – which was first declared in January 2020 and extended several times since then – plays a key role in various rules related to health insurance coverage.For the duration of the emergency period, for example, most health insurance plans must cover the cost of erectile dysfunction treatment testing can u buy viagra over the counter and treatments without cost-sharing. States will continue to receive additional federal matching funds for Medicaid through June 2021, and cannot disenroll can u buy viagra over the counter people from their Medicaid programs during the erectile dysfunction treatment emergency period, unless the person moves out of state or requests a coverage termination.

The public health emergency also expands access to telehealth and reduces reporting burdens for hospitals.Tennessee’s Medicaid block grant waiver approvedIn November 2019, Tennessee submitted a waiver proposal to CMS, seeking approval to transition to a block grant funding approach for the state’s Medicaid program. Last week the Trump administration announced that the state’s proposal had been approved for 10 years, with the extended timeframe can u buy viagra over the counter intended to “reduce administrative burden and allow the state sufficient time to evaluate its innovative approach.” Instead of the open-ended matching system that the federal government uses with the rest of the states, Tennessee will have an annual spending cap, which can grow if enrollment grows, but which will not adjust to keep up with increasing healthcare spending.In its approval letter, the Trump administration repeatedly touts the flexibility that the block grant waiver will provide for Tennessee. But block grants for Medicaid funding have been widely panned by public health experts, and are strongly opposed by leading patient advocacy groups due to the potential for reduced benefits, increased costs for enrollees, reductions in payments to providers, and state budget shortfalls.Although the incoming Biden administration can make changes to 1115 waivers via a review process, Margo Sanger-Katz reported last can u buy viagra over the counter week that CMS has sent letters to all 45 states that have active waivers, asking them to sign contracts that would make it harder for a new administration to terminate waivers “on a political whim.”CMS auditing hospitals for compliance with new price transparency requirementsThe hospital price transparency rule that CMS finalized in late 2019 took effect on January 1. It requires hospitals to “provide clear, accessible pricing information online” for 300 “shoppable” services, in both machine-readable and consumer-friendly formats. And the pricing information has to include payer-specific negotiated rates, which is much more useful than hospital “chargemaster” rates that don’t really reflect the amounts that payers and consumers actually pay.There is widespread anecdotal evidence that compliance is spotty thus far (and the maximum annual penalty for non-compliance would only amount to about $100,000, which is equal to about four hospital admissions), but CMS is currently conducting an audit of some hospitals to can u buy viagra over the counter determine whether they’re in compliance with the new rule.

Hospital compliance is expected to ramp up in the coming weeks, but a lot remains to be seen in terms of how much can u buy viagra over the counter impact the transparency rules will actually have on consumer decision-making.Legislation in Minnesota would expand MinnesotaCare, create a public optionHF11, sponsored by Rep. Jennifer Shultz (DFL, District 7A), was introduced in Minnesota last week, calling for various changes to the MinnesotaCare program that would allow more people to enroll. MinnesotaCare is a Basic Health Program, which provides coverage to people who aren’t eligible for can u buy viagra over the counter Medicaid and who have household incomes of up to 200 percent of the poverty level.HF11 would extend MinnesotaCare eligibility to undocumented immigrants, and would also eliminate the “family glitch” for MinnesotaCare eligibility. HF11 would also create a public option, via MinnesotaCare buy-in, for people with income can u buy viagra over the counter above 200 percent of the poverty level, with a sliding fee scale for premiums. The legislation would also allow small employers to buy into the MinnesotaCare program as a means of providing coverage for their employees.Rep.

Shultz published an op-ed in the Minnesota Reformer last week, outlining her goals for health care reform and the incremental steps that Minnesota could take to make coverage and care more accessible and affordable in the state.Utah Insurance Department proposes new minimum standards for short-term health plansThe Utah Insurance Department has proposed new minimum standards for short-term health insurance coverage, including a benefit cap of at least $1 million, copayments/coinsurance that can’t exceed 50 percent of covered charges, and various inpatient and outpatient services that can u buy viagra over the counter would have to be covered. But the three benefit categories that are most commonly excluded on short-term plans – outpatient prescription drugs, mental health care, and maternity care – are not among can u buy viagra over the counter the mandated benefits that the Department has proposed. The Department is accepting public comments on the proposal until March 3.BCBS Association suspends contributions to members of Congress who voted to reject electoral college resultsLast Friday, the Blue Cross Blue Shield Association announced that it was suspending political contributions “to lawmakers who voted to undermine our democracy,” referring to the members who challenged the electoral college results from the November presidential election. Numerous other companies have followed suit, including Disney and Wal-Mart, but the Blue Cross Blue Shield can u buy viagra over the counter Association was the first major healthcare group to take this step. Others have can u buy viagra over the counter since announced similar decisions, including PhRMA, and to a lesser degree, Cigna.

The Blue Cross Blue Shield Association represents the 36 independent Blue Cross Blue Shield insurers that operate across the country, insuring more than 107 million Americans.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens can u buy viagra over the counter of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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They discovered a unique subset of these ILC3s that generic viagra reviews circulate in the bloodstream and can infiate the brain -- and, to their surprise, do not quench inflammation but instead ignite it.The scientists called this subset inflammatory ILC3s, and found them in the central nervous system of mice with a condition modeling MS. Instead of constraining the immune response, this subset of ILC3s spurred another group of immune cells called T cells to attack myelinated nerve fibers, leading to MS-like disease symptoms. The researchers detected similar inflammatory ILC3s in the peripheral blood and cerebrospinal fluid of MS patients."This work has the potential to inform our understanding of, and potential generic viagra reviews treatments for, a broad variety of conditions involving T-cell infiation of the brain," said senior author Dr.

Gregory Sonnenberg, associate professor of microbiology and immunology in medicine in the Division of Gastroenterology and Hepatology and a member of the Jill Roberts Institute for Research in Inflammatory Bowel Disease at Weill Cornell Medicine.MS affects more than two million people worldwide. Other conditions that feature chronic generic viagra reviews brain inflammation afflict tens of millions more and include Alzheimer's and Parkinson's diseases. There is also evidence that neuroinflammation develops naturally with aging and is a major factor in age-related cognitive decline, and more recently inflammatory T-cell responses in the brain have been linked to neurological symptoms associated with erectile dysfunction .The researchers have shown in recent work that ILC3s residing in the gut act as sentinels and immune regulators, suppressing inflammation -- including inflammatory T-cell activity -- and warding off cancer.

In the new study, they examined the roles of ILC3s in the generic viagra reviews brain, and found, contrary to their expectation, that ILC3s are not normally present in the brain under healthy conditions but can infiate the brain from the bloodstream during inflammation. When they do infiate the central nervous system, they have pro-inflammatory rather than anti-inflammatory effects. advertisement The researchers showed with a mouse model of MS that these inflammatory ILC3s in generic viagra reviews the brain function as antigen-presenting cells.

They display bits of myelin protein, the main ingredient in the insulating layer around nerve fibers, to T cells -- prompting them to attack myelin, causing the nerve damage that gives rise to disease signs. They found the inflammatory ILC3s in close association with T cells in regions of active inflammation and nerve damage in the mouse brains."The infiation of these inflammatory ILC3s to generic viagra reviews the brains and spinal cords of mice coincides with the onset and peak of disease," said first author John Benji Grigg, a Weill Cornell Graduate School of Medical Sciences doctoral candidate in the Sonnenberg laboratory. "Further, our experimental data in mice demonstrate these immune cells play a key role in driving the pathogenesis of neuro-inflammation."The researchers discovered that they could prevent MS-like disease in the animals by removing from the ILC3s a key molecule called MHCII, which normally is used in the antigen-presenting process -- the removal essentially blocks the cells' ability to activate myelin-attacking T cells."Despite our very best disease-modifying therapies for MS, patients continue to progress, and since disease onset is early in life, they face the prospect of permanent physical and cognitive disability," said co-author Dr.

Tim Vartanian, professor of generic viagra reviews neuroscience in the Feil Family Brain and Mind Institute at Weill Cornell Medicine, chief of the division of multiple sclerosis and neuro-immunology and a professor of neurology in the Department of Neurology at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center. "Identification of inflammatory ILC3s with antigen presentation capabilities in the central nervous system of people with MS offers a new strategic target to prevent nervous system injury."Finally, the researchers discovered that ILC3s that reside in other tissues in the body can be programmed, in effect, to counter the activity of brain-infiating T cells, preventing the MS-like condition disease in mice.This work was completed in close collaboration with Dr. Ari Waisman, director of the Institute for Molecular Medicine at the University Medical Center of Johannes Gutenberg University Mainz, where the researchers built on prior research demonstrating that there are gut-resident ILC3s that display antigens to T cells in a slightly different way to promote T-cell inactivity, or "tolerance." The researchers demonstrated that by experimentally exposing these tolerance-inducing intestinal ILC3s to myelin, they could block neuroinflammatory T-cell activity and the generic viagra reviews development of MS-like disease in the mice.The work therefore points to the possibility that MS and potentially many other inflammatory conditions could someday be treated either by directly inhibiting the activity of inflammatory ILC3s that infiate the brain, or by targeting self-antigens to the intestinal ILC3s that promote tolerance in other tissues, Dr.

Sonnenberg said.Today, people living with HIV/AIDS can remain healthy if they are able to engage in routine care and take the medicines that reduce their viagra to undetectable levels. But for people with HIV who are also struggling with depression, that's often an insurmountable challenge, especially in South Africa, home to the highest number of cases in the world and a significant shortage of mental health professionals.But a new study in the Journal of the International AIDS Society has local and global implications for successfully treating both mental health and HIV/AIDS in settings like South Africa -- or even Miami, the epicenter of new cases in the United States.In the study, an international team of researchers -- led by the University of Miami's Steven Safren and two colleagues -- demonstrated the effectiveness of training nurses in public HIV clinics to deliver a specially adapted cognitive behavior therapy (CBT) to help people with depression and uncontrolled HIV adhere to generic viagra reviews their prescribed medication regiment. CBT is a proven approach for changing faulty or unhelpful thinking or behavioral patterns."We know that treating HIV-positive people who are clinically depressed with antidepressants alone does not affect their viral loads.

Their depression may improve, but their adherence does not," said Safren, professor of psychology and director of the University's Center for HIV/AIDS Research and Mental generic viagra reviews Health. "So, given the global shortage of mental health professionals, we showed it is possible to train nurses to deliver cognitive-behavioral therapy for adherence and depression (CBT-AD), an intervention that successfully addresses both clinical depression and uncontrolled HIV."Safren, who joined the University in 2015 from Harvard Medical School, conducted the generic viagra reviews study in a poor township just outside of Cape Town, South Africa, with fellow researchers John A. Joska, director of the HIV Mental Health Research Unit and professor of psychiatry at the University of Cape Town, and Conall O'Cleirigh, associate professor of psychology at Harvard and director of Behavioral Medicine at Massachusetts General Hospital.For their study, the researchers recruited 161 patients with uncontrolled HIV/AIDS and clinical depression from four public health clinics in the township of Khayelitsha.

Although a generic viagra reviews medical officer could prescribe antidepressants to the patients, the clinics have limited psychological services -- as does the country in general. According to the study, South Africa only has 0.28 psychiatrists and 0.32 psychologists per 100,000 people. advertisement At the onset of the study, all participants received the usual enhanced care for clinically depressed HIV-AIDS patients who did not generic viagra reviews achieve viral suppression after receiving the first month of their antiretroviral medication.

That customary treatment included another prescription and follow-up meetings with an adherence counselor.But half the patients were also randomly assigned to attend eight CBT-AD sessions, where specially trained nurses integrated strategies for treating depression with adherence counseling that included modules on life skills, depression, relaxation, mood monitoring, and problem-solving.The idea, Safren said, was to help patients "turn down the volume" of their mental health symptoms, so they would be more open to counseling on the benefit of taking their medication. To track their adherence, the patients also received an electronic pill box that, every time it was opened, transmitted a real-time signal to a web server.And, generic viagra reviews researchers found, the task-shared approach delivered by nurses proved effective. Patients who completed the CBT-AD sessions were more than 2.5 times more likely to achieve undetectable viral loads that those who underwent the usual care.Now, Safren noted, the next step will be for the research team to evaluate how to sustainably implement the CBT-AD approach in South Africa, or even South Florida.

He said the task-shared approach could be viable in Miami, where there are fewer services to help people generic viagra reviews achieve viral suppression than in other U.S. Cities with large populations of people living with the viagra."South Africa has the most cases of HIV/AIDS in the world and Miami is the city with the highest incidence of new cases in the U.S. -- so there is generic viagra reviews a parallel," Safren pointed out.

"And unlike places like New York or Massachusetts, where people are more likely to be virally suppressed, Florida doesn't have the same public health resources. If, for example, you're an HIV patient at Massachusetts General or Fenway generic viagra reviews Health, where I used to work, and you miss your visit, or your viral load becomes uncontrolled, social workers will swoop in and provide assistance. That doesn't happen as often in Florida and other places in the U.S.

With less generic viagra reviews public health HIV/AIDS funding."In addition to Safren, Joska, and O'Cleirigh, other co-authors on the study included Jasper S. Lee, a Ph.D. Student, and Sierra A generic viagra reviews.

Bainter, an assistant professor, both in the Department of Psychology at the University. As well as researchers from the University of Maryland, College Park generic viagra reviews. The University of Science and Technology in Mbarara, Uganda.

The University generic viagra reviews of Washington in Seattle. And Stellenbosch University in Stellenbosch, South Africa..

A group of immune cells that normally protect against inflammation in the gastrointestinal tract may have the opposite effect in multiple sclerosis (MS) and other brain inflammation-related conditions, according to a new study by Weill Cornell Medicine and NewYork-Presbyterian can u buy viagra over the counter researchers. The results suggest that countering the activity of these cells could be a new therapeutic approach for such conditions.The researchers, who can u buy viagra over the counter reported their finding Dec. 1 in Nature, were studying a set of immune cells called group 3 innate lymphoid cells (ILC3s), which help the immune system tolerate beneficial microbes and suppress inflammation in the intestines and other organs throughout the body.

They discovered a unique subset of these ILC3s that circulate in the bloodstream and can infiate the brain -- and, to can u buy viagra over the counter their surprise, do not quench inflammation but instead ignite it.The scientists called this subset inflammatory ILC3s, and found them in the central nervous system of mice with a condition modeling MS. Instead of constraining the immune response, this subset of ILC3s spurred another group of immune cells called T cells to attack myelinated nerve fibers, leading to MS-like disease symptoms. The researchers detected similar inflammatory ILC3s can u buy viagra over the counter in the peripheral blood and cerebrospinal fluid of MS patients."This work has the potential to inform our understanding of, and potential treatments for, a broad variety of conditions involving T-cell infiation of the brain," said senior author Dr.

Gregory Sonnenberg, associate professor of microbiology and immunology in medicine in the Division of Gastroenterology and Hepatology and a member of the Jill Roberts Institute for Research in Inflammatory Bowel Disease at Weill Cornell Medicine.MS affects more than two million people worldwide. Other conditions that feature chronic brain inflammation afflict tens of millions can u buy viagra over the counter more and include Alzheimer's and Parkinson's diseases. There is also evidence that neuroinflammation develops naturally with aging and is a major factor in age-related cognitive decline, and more recently inflammatory T-cell responses in the brain have been linked to neurological symptoms associated with erectile dysfunction .The researchers have shown in recent work that ILC3s residing in the gut act as sentinels and immune regulators, suppressing inflammation -- including inflammatory T-cell activity -- and warding off cancer.

In the new study, they examined the roles of ILC3s in the brain, and found, contrary to their expectation, that ILC3s are not normally present in the brain can u buy viagra over the counter under healthy conditions but can infiate the brain from the bloodstream during inflammation. When they do infiate the central nervous system, they have pro-inflammatory rather than anti-inflammatory effects. advertisement The researchers showed with a mouse model of MS that these inflammatory ILC3s in the brain can u buy viagra over the counter function as antigen-presenting cells.

They display bits of myelin protein, the main ingredient in the insulating layer around nerve fibers, to T cells -- prompting them to attack myelin, causing the nerve damage that gives rise to disease signs. They found the inflammatory ILC3s in close association with T cells in regions of active inflammation and nerve damage can u buy viagra over the counter in the mouse brains."The infiation of these inflammatory ILC3s to the brains and spinal cords of mice coincides with the onset and peak of disease," said first author John Benji Grigg, a Weill Cornell Graduate School of Medical Sciences doctoral candidate in the Sonnenberg laboratory. "Further, our experimental data in mice demonstrate these immune cells play a key role in driving the pathogenesis of neuro-inflammation."The researchers discovered that they could prevent MS-like disease in the animals by removing from the ILC3s a key molecule called MHCII, which normally is used in the antigen-presenting process -- the removal essentially blocks the cells' ability to activate myelin-attacking T cells."Despite our very best disease-modifying therapies for MS, patients continue to progress, and since disease onset is early in life, they face the prospect of permanent physical and cognitive disability," said co-author Dr.

Tim Vartanian, professor of neuroscience can u buy viagra over the counter in the Feil Family Brain and Mind Institute at Weill Cornell Medicine, chief of the division of multiple sclerosis and neuro-immunology and a professor of neurology in the Department of Neurology at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center. "Identification of inflammatory ILC3s with antigen presentation capabilities in the central nervous system of people with MS offers a new strategic target to prevent nervous system injury."Finally, the researchers discovered that ILC3s that reside in other tissues in the body can be programmed, in effect, to counter the activity of brain-infiating T cells, preventing the MS-like condition disease in mice.This work was completed in close collaboration with Dr. Ari Waisman, director of the Institute for Molecular Medicine at the University Medical Center of Johannes Gutenberg can u buy viagra over the counter University Mainz, where the researchers built on prior research demonstrating that there are gut-resident ILC3s that display antigens to T cells in a slightly different way to promote T-cell inactivity, or "tolerance." The researchers demonstrated that by experimentally exposing these tolerance-inducing intestinal ILC3s to myelin, they could block neuroinflammatory T-cell activity and the development of MS-like disease in the mice.The work therefore points to the possibility that MS and potentially many other inflammatory conditions could someday be treated either by directly inhibiting the activity of inflammatory ILC3s that infiate the brain, or by targeting self-antigens to the intestinal ILC3s that promote tolerance in other tissues, Dr.

Sonnenberg said.Today, people living with HIV/AIDS can remain healthy if they are able to engage in routine care and take the medicines that reduce their viagra to undetectable levels. But for people with HIV who are also struggling with depression, that's often an insurmountable challenge, especially in South Africa, home to the highest number of cases in the world and a significant shortage of mental health professionals.But a new study in the Journal of the International AIDS Society has can u buy viagra over the counter local and global implications for successfully treating both mental health and HIV/AIDS in settings like South Africa -- or even Miami, the epicenter of new cases in the United States.In the study, an international team of researchers -- led by the University of Miami's Steven Safren and two colleagues -- demonstrated the effectiveness of training nurses in public HIV clinics to deliver a specially adapted cognitive behavior therapy (CBT) to help people with depression and uncontrolled HIV adhere to their prescribed medication regiment. CBT is a proven approach for changing faulty or unhelpful thinking or behavioral patterns."We know that treating HIV-positive people who are clinically depressed with antidepressants alone does not affect their viral loads.

Their depression may improve, but their adherence does not," said Safren, professor of psychology and director of the University's Center for HIV/AIDS Research and Mental Health can u buy viagra over the counter. "So, given the can u buy viagra over the counter global shortage of mental health professionals, we showed it is possible to train nurses to deliver cognitive-behavioral therapy for adherence and depression (CBT-AD), an intervention that successfully addresses both clinical depression and uncontrolled HIV."Safren, who joined the University in 2015 from Harvard Medical School, conducted the study in a poor township just outside of Cape Town, South Africa, with fellow researchers John A. Joska, director of the HIV Mental Health Research Unit and professor of psychiatry at the University of Cape Town, and Conall O'Cleirigh, associate professor of psychology at Harvard and director of Behavioral Medicine at Massachusetts General Hospital.For their study, the researchers recruited 161 patients with uncontrolled HIV/AIDS and clinical depression from four public health clinics in the township of Khayelitsha.

Although a medical officer could prescribe antidepressants to the patients, the clinics have limited psychological can u buy viagra over the counter services -- as does the country in general. According to the study, South Africa only has 0.28 psychiatrists and 0.32 psychologists per 100,000 people. advertisement At the onset of the study, all participants received the usual enhanced care for clinically depressed HIV-AIDS patients who did not achieve viral suppression can u buy viagra over the counter after receiving the first month of their antiretroviral medication.

That customary treatment included another prescription and follow-up meetings with an adherence counselor.But half the patients were also randomly assigned to attend eight CBT-AD sessions, where specially trained nurses integrated strategies for treating depression with adherence counseling that included modules on life skills, depression, relaxation, mood monitoring, and problem-solving.The idea, Safren said, was to help patients "turn down the volume" of their mental health symptoms, so they would be more open to counseling on the benefit of taking their medication. To track their can u buy viagra over the counter adherence, the patients also received an electronic pill box that, every time it was opened, transmitted a real-time signal to a web server.And, researchers found, the task-shared approach delivered by nurses proved effective. Patients who completed the CBT-AD sessions were more than 2.5 times more likely to achieve undetectable viral loads that those who underwent the usual care.Now, Safren noted, the next step will be for the research team to evaluate how to sustainably implement the CBT-AD approach in South Africa, or even South Florida.

He said can u buy viagra over the counter the task-shared approach could be viable in Miami, where there are fewer services to help people achieve viral suppression than in other U.S. Cities with large populations of people living with the viagra."South Africa has the most cases of HIV/AIDS in the world and Miami is the city with the highest incidence of new cases in the U.S. -- so there is a parallel," can u buy viagra over the counter Safren pointed out.

"And unlike places like New York or Massachusetts, where people are more likely to be virally suppressed, Florida doesn't have the same public health resources. If, for example, you're an HIV patient can u buy viagra over the counter at Massachusetts General or Fenway Health, where I used to work, and you miss your visit, or your viral load becomes uncontrolled, social workers will swoop in and provide assistance. That doesn't happen as often in Florida and other places in the U.S.

With less public health HIV/AIDS funding."In addition to Safren, Joska, and O'Cleirigh, other co-authors on the study included Jasper S can u buy viagra over the counter. Lee, a Ph.D. Student, and Sierra can u buy viagra over the counter A.

Bainter, an assistant professor, both in the Department of Psychology at the University. As well as researchers can u buy viagra over the counter from the University of Maryland, College Park. The University of Science and Technology in Mbarara, Uganda.

The University can u buy viagra over the counter of Washington in Seattle. And Stellenbosch University in Stellenbosch, South Africa..

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The U.S viagra super active. Department of Agriculture’s National Institute of Food and Agriculture (NIFA) announced recently departments across the country were receiving nearly $25 million in grants to support projects aimed to alleviate stress for agricultural workers. The 50 grants support programs ranging from preventing viagra super active suicide to marriage and relationship counseling. “NIFA’s Farm and Ranch Stress Assistance Network connects farmers, ranchers and others in agriculture-related occupations to stress assistance programs,” said NIFA Director Dr. Carrie Castille in a statement.

€œCreating and expanding a network to assist farmers and ranchers in times of stress can increase behavioral health awareness, literacy and positive outcomes for agricultural producers, workers and viagra super active their families.” NIFA says that even before the viagra effects on the agricultural sector, stress was on the rise among those in the industry. Ray Atkinson is the spokesman for the American Farm Bureau Federation. The organization runs a Farm State of Mind campaign, which includes research, a directory of resources, training, and tips on starting a conversation. Though they are not direct beneficiaries of the viagra super active grant, they work with many of the grant recipients. “It sounds cliche, but…it’s totally true that it’s OK not to be OK,” Atkinson said in a Zoom interview with The Daily Yonder.

€œFarmers help farmers. We know farmers help farmers, and so it’s about really just encouraging folks to look out for neighbors, friends, and viagra super active family. And just start this conversation. Just be viagra super active there. Be willing to be there for people.” During the height of the viagra, in January 2021, the American Farm Bureau released a survey that found a majority of farmers and farmworkers said the erectile dysfunction treatment viagra had impacted their mental health, and more than half said they were personally experiencing more mental health challenges than they were a year before then.

Like this story?. Sign up for viagra super active our newsletter. “My takeaway from this survey is that the need for support is real and we must not allow lack of access or a ‘too tough to need help’ mentality to stand in the way,” said AFBF President Zippy Duvall at the time of the release of the survey. “We are stepping up our efforts through our Farm State of Mind campaign, encouraging conversations about stress and mental health and providing free training and resources for farm and ranch families and rural communities.” In Minnesota, NIFA awarded the State Department of Agriculture $500,000 for its Bend, Don’t Break project. The project viagra super active will engage agency, nonprofit, and educational partners in helping farmers and others in agriculture cope with adversity, addressing suicide, farm transition/succession, legal problems, family relationships and youth stress.

Some of the organizations are legacy organizations, said Meg Moynihan, senior advisor on Strategy &. Innovation at the Minnesota Department of Agriculture. “We think our farmers are far more likely to be receptive to groups and organizations they already know,” she said viagra super active in a phone interview. One such program is a network of mostly retired farmers, who act as advocates for current farmers experiencing hardships. They currently have 10 farmer advocates across the state and viagra super active will be hiring one more, she said.

There is also money earmarked toward non-traditional farmers, which includes immigrant farmers. €œWe have quite a substantial and growing number of Latino and Hispanic farmers,” Moynihan said. €œPeople from Hmong origin, who have come from Laos and their family settled as refugees, or they themselves resettled and also attract new people from Africa, different countries in Africa.” Some projects will viagra super active work specifically with Latino, Indigenous, and African farmers and farm workers. As the results of the survey showed, Moynihan said stress has increased due to the viagra for a variety of reasons, including market fluctuations and supply disruptions, familiar strains, and more. “During the viagra, families were thrown together in a way that they aren’t usually thrown together,” she said.

€œIn some cases, the spouse who worked on a farm and was bringing in crucial income and benefits to viagra super active the farm, perhaps was furloughed or their business closed, or their hours were severely cut. And so that presented some financial challenges to the farm.” To help with family-related issues, the Minnesota Department of Agriculture will be funding a series of retreats for farm couples to have firsthand experience with a psychologist and facilitators to work through issues, she said. The retreats are for “people who are finding their relationships balancing in different ways and want to explore that.” You Might Also Like.

The U.S can u buy viagra over the counter. Department of Agriculture’s National Institute of Food and Agriculture (NIFA) announced recently departments across the country were receiving nearly $25 million in grants to support projects aimed to alleviate stress for agricultural workers. The 50 grants support can u buy viagra over the counter programs ranging from preventing suicide to marriage and relationship counseling. “NIFA’s Farm and Ranch Stress Assistance Network connects farmers, ranchers and others in agriculture-related occupations to stress assistance programs,” said NIFA Director Dr. Carrie Castille in a statement.

€œCreating and expanding a network to assist farmers and ranchers in times of stress can increase behavioral health awareness, literacy and positive outcomes for agricultural producers, workers and their families.” NIFA says that even before the viagra effects on the agricultural can u buy viagra over the counter sector, stress was on the rise among those in the industry. Ray Atkinson is the spokesman for the American Farm Bureau Federation. The organization runs a Farm State of Mind campaign, which includes research, a directory of resources, training, and tips on starting a conversation. Though they are can u buy viagra over the counter not direct beneficiaries of the grant, they work with many of the grant recipients. “It sounds cliche, but…it’s totally true that it’s OK not to be OK,” Atkinson said in a Zoom interview with The Daily Yonder.

€œFarmers help farmers. We know can u buy viagra over the counter farmers help farmers, and so it’s about really just encouraging folks to look out for neighbors, friends, and family. And just start this conversation. Just be can u buy viagra over the counter there. Be willing to be there for people.” During the height of the viagra, in January 2021, the American Farm Bureau released a survey that found a majority of farmers and farmworkers said the erectile dysfunction treatment viagra had impacted their mental health, and more than half said they were personally experiencing more mental health challenges than they were a year before then.

Like this story?. Sign up for our newsletter can u buy viagra over the counter. “My takeaway from this survey is that the need for support is real and we must not allow lack of access or a ‘too tough to need help’ mentality to stand in the way,” said AFBF President Zippy Duvall at the time of the release of the survey. “We are stepping up our efforts through our Farm State of Mind campaign, encouraging conversations about stress and mental health and providing free training and resources for farm and ranch families and rural communities.” In Minnesota, NIFA awarded the State Department of Agriculture $500,000 for its Bend, Don’t Break project. The project will engage agency, nonprofit, and educational partners in helping farmers and others in agriculture cope can u buy viagra over the counter with adversity, addressing suicide, farm transition/succession, legal problems, family relationships and youth stress.

Some of the organizations are legacy organizations, said Meg Moynihan, senior advisor on Strategy &. Innovation at the Minnesota Department of Agriculture. “We think our farmers are far more likely to be receptive to groups and organizations they already know,” she said in a phone interview can u buy viagra over the counter. One such program is a network of mostly retired farmers, who act as advocates for current farmers experiencing hardships. They currently have 10 farmer advocates across the state and will be hiring one more, she can u buy viagra over the counter said.

There is also money earmarked toward non-traditional farmers, which includes immigrant farmers. €œWe have quite a substantial and growing number of Latino and Hispanic farmers,” Moynihan said. €œPeople from Hmong origin, who have come from Laos and their family settled as refugees, or they themselves resettled and also attract new people from Africa, different countries in Africa.” can u buy viagra over the counter Some projects will work specifically with Latino, Indigenous, and African farmers and farm workers. As the results of the survey showed, Moynihan said stress has increased due to the viagra for a variety of reasons, including market fluctuations and supply disruptions, familiar strains, and more. “During the viagra, families were thrown together in a way that they aren’t usually thrown together,” she said.

€œIn some cases, the spouse who worked on a farm and was bringing in crucial income and benefits to can u buy viagra over the counter the farm, perhaps was furloughed or their business closed, or their hours were severely cut. And so that presented some financial challenges to the farm.” To help with family-related issues, the Minnesota Department of Agriculture will be funding a series of retreats for farm couples to have firsthand experience with a psychologist and facilitators to work through issues, she said. The retreats are for “people who are finding their relationships balancing in different ways and want to explore that.” You Might Also Like.

Viagra before and after pics

How to cite this article:Singh viagra before and after pics O P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one viagra before and after pics 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 viagra before and after pics media 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, viagra before and after pics 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, 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 their patients in despair viagra before and after pics 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 viagra before and after pics (1) 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 about the person's mental condition and illness and also his relationships and viagra before and after pics 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 viagra before and after pics 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 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 viagra before and after pics were quoted, or “misquoted,” or “quoted out of context,” commenting on the 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 viagra before and after pics 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 viagra before and after pics 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 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 prompt viagra before and after pics 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 viagra before and after pics 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 Interest viagra before and after pics. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) viagra before and after pics 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 viagra before and after pics mainly 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 viagra before and after pics 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 structural, functional, viagra before and after pics 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 that ECT has viagra before and after pics 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, viagra before and after pics brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update viagra before and after pics.

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 viagra before and after pics 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 within the brain that may be viagra before and after pics 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 necessarily viagra before and after pics 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 how ECT acts rather than evidence viagra before and after pics 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] and [Table viagra before and after pics 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 received ECT in the past viagra before and after pics.

In the absence of baseline neuroimaging, it would be very difficult to attribute any structural brain changes to ECT. In addition, pneumoencephalography, CT viagra before and after pics 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] viagra before and after pics While 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 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 viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics brain tissue changes following ECT.[17]The next major breakthrough came in 2010 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 viagra before and after pics volume increase in any part of the brain following 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 brain damage, the newer studies viagra before and after pics 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 inconsistencies to this viagra before and after pics 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 viagra before and after pics by 6 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 viagra before and after pics 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 viagra before and after pics following ECT, and symptom improvement was correlated with an increase 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 viagra before and after pics 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 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 schizophrenia and the effect of ECT on the same viagra before and after pics. 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 viagra before and after pics 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 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 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 viagra before and after pics 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 viagra before and after pics 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 upon by some to claim that ECT causes brain damage.[46] Such statements viagra before and after pics 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 viagra before and after pics 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 would also be correspondingly viagra before and after pics 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 its viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics a 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 viagra before and after pics demonstrated 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 have viagra before and after pics 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 viagra before and after pics 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, viagra before and after pics who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and 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] with a trend level increase in Cho levels, which viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics 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, viagra before and after pics 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 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 conjecture, and more work viagra before and after pics 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 protein viagra before and after pics 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 viagra before and after pics 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 memory, verbal episodic memory, viagra before and after pics 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 viagra before and after pics of 2 weeks and thereafter, a majority of cognitive 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 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 viagra before and after pics 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 viagra before and after pics 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 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 viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics changes have been localized to the hippocampus, amygdala, and 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, these impairments are transient with full recovery within a span of 2 viagra before and after pics 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 viagra before and after pics 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 viagra before and after pics 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 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 viagra before and after pics question.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Payne NA, Prudic J.

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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 this how to get a viagra prescription from your doctor article:Singh O P can u buy viagra over the counter. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one of the can u buy viagra over the counter 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 went into a frenzy as newspapers, news channels, and social media were full of stories providing minute details of the suicidal can u buy viagra over the counter 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, print, and can u buy viagra over the counter 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 their patients can u buy viagra over the counter 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 can u buy viagra over the counter 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 about the person's mental condition and illness and can u buy viagra over the counter 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 training of psychiatrists regarding the proper way of interaction with media can u buy viagra over the counter. 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 u buy viagra 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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 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 prompt reporters to seek psychiatrists for their expert opinion can u buy viagra over the counter. 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 can u buy viagra over the counter – 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 can u buy viagra over the counter of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective modality can u buy viagra over the counter 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 can u buy viagra over the counter of ECT has been mainly 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 can u buy viagra over the counter 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 structural, functional, and can u buy viagra over the counter 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 that ECT has a demonstrable impact can u buy viagra over the counter 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, can u buy viagra over the counter brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update can u buy viagra 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 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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 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 indirect evidences available through studies that have been designed to can u buy viagra over the counter 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 can u buy viagra over the counter structural and functional brain changes which might explain 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] and [Table 2] provide an overview can u buy viagra over the counter 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 can u buy viagra over the counter design, with neuroimaging being done in patients who had 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 lower spatial can u buy viagra over the counter 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 can u buy viagra over the counter 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 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 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 can u buy viagra over the counter 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 amygdala–hippocampal complex.[10] This was, however, something which would later can u buy viagra over the counter 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 can u buy viagra over the counter 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 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 can u buy viagra over the counter following 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 can u buy viagra over the counter looking for the evidence 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, can u buy viagra over the counter 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 can u buy viagra over the counter to baseline by 6 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 can u buy viagra over the counter 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 can u buy viagra over the counter symptom improvement was correlated with an increase 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 can u buy viagra over the counter in 2015 constructed large-scale 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 can u buy viagra over the counter in patients with 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 can u buy viagra over the counter 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 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 can u buy viagra over the counter brain regions, the heterogeneity 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 right unilateral ECT was associated with greater volume increase in the can u buy viagra over the counter 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 upon by some to claim that ECT causes brain damage.[46] can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter concentration of these metabolites is at least 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated can u buy viagra over the counter a 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] can u buy viagra over the counter have demonstrated 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 have analyzed can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter NAA levels were significantly reduced in the left ACC in patients with depression and 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 can u buy viagra over the counter to this, one study 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 u buy viagra 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 can u buy viagra over the counter same finding.[33],[38] Cho levels have also been 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 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 can u buy viagra over the counter 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 conjecture, and more work needs to be done in this area can u buy viagra over the counter. 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 protein molecules which mediate neuronal survival and can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter cognitive domains 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 can u buy viagra over the counter resolved within a span of 2 weeks and thereafter, a majority of cognitive 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 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 can u buy viagra over the counter 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 can u buy viagra over the counter sine-wave era in contemporary ECT practice.Another 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 by Devanand et can u buy viagra over the counter 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 can u buy viagra over the counter studies reveal is 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 can u buy viagra over the counter have been localized to the hippocampus, amygdala, and 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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 can u buy viagra over the counter 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.

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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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