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NSW has reported 11 new cases of locally transmitted COVID‑19 helpful hints in how to get zestril without prescription the 24 hours to 8pm last night.Three cases in overseas travellers in hotel quarantine were also diagnosed. One case was temporarily reclassified from a confirmed to probable case on 12 October while under review is re-included today, having now being confirmed as a positive case. This brings the total number of how to get zestril without prescription cases in NSW to 4,121.NSW Health thanks the community for responding to calls for increased testing, with 16,021 tests reported to 8pm last night, compared with 8,609 in the previous 24 hours. Confirmed cases (including interstate residents in NSW health care facilities) 4,121 Deaths (in NSW from confirmed cases)​​ 55 Total tests carried out 2,843,545 Of the new cases to 8pm last night. Three were acquired overseas and are now in hotel quarantineeleven were locally acquired, and all are linked to known casesNine how to get zestril without prescription of the new cases reported today are linked to the Lakemba GP cluster, which now has 12 cases in total.

All nine cases are household or other contacts of known cases, including three who attended the clinic. Contact tracing and investigations into the how to get zestril without prescription source of the cluster continue. Two of the new cases reported today are linked to the private clinic cluster, which now has 10 cases in total. One case attended the clinic, and the other is a staff member how to get zestril without prescription at the clinic. Contact tracing and investigations into the source of the cluster continue.

One of how to get zestril without prescription the new cases of COVID-19 reported today attended the Narellan Town Centre on Camden Valley Way on 7 October from 11.30am to 1pm. Anyone who attended this venue at this time is considered a casual contact and must monitor for symptoms and get tested immediately if they develop. After testing, they must remain in isolation until a negative test result is received.Everyone plays an important role in helping to contain the pandemic by testing quickly how to get zestril without prescription and following social distancing rules. Get tested on the day you get symptoms – don’t wait to see if they go away. Assume it’s COVID-19 until proven otherwise by a test.

There is how to get zestril without prescription no limit on how many tests you can have. Testing is quick, free, and easy and most people receive their test result within 24 hours. If you have even the mildest of symptoms like a runny nose or scratchy throat, cough, fever or other symptoms that could be COVID-19, please come forward for testing right away how to get zestril without prescription. A full list of COVID-19 testing clinics is available or people can visit their GP.NSW Health is treating 62 COVID-19 cases, including one in intensive care who does not require ventilation. Ninety-four per cent how to get zestril without prescription of cases being treated by NSW Health are in non-acute, out-of-hospital care.COVID-19 is still likely circulating in the community and we must all be vigilant.

To help stop the spread of COVID-19. If you are unwell, get tested and isolate right away – don’t how to get zestril without prescription delay.Wash your hands regularly. Take hand sanitiser with you when you go out.Keep your distance. Leave 1.5 how to get zestril without prescription metres between yourself and others. Wear a mask when using public transport, rideshares and taxis, and in shops, places of worship and other places where you can’t physically distance.

When taking taxis or rideshares, commuters should also sit in the back.Locations linked to known cases, advice on testing and isolation, and areas identified for increased testing can be at NSW Government - Latest news and updates.Confirmed cases to dateOverseas 2,196Interstate acquired 91Locally acquired – contact of a confirmed case and/or in a known cluster 1,439Locally acquired ​– contact not identified 395Under investigation 0 Counts reported for a particular day may vary over time with ongoing enhanced surveillance activities.Returned travellers in hotel quarantine to dateSymptomatic travellers tested 5,836Found positive 138 Asymptomatic travellers screened at day 2 34,177Found positive166 Asymptomatic travellers screened at day 1046,724Found positive127Video update​.

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How to cite this zestril dosage article:Singh O P zestril 20mg tablet. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide zestril dosage is one of the highly publicized events in our country.

Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, the media went into a frenzy as newspapers, news zestril dosage channels, and social media were full of stories providing minute details of the suicidal act. Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor.

All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and their private and personal details were freely and blatantly broadcast and discussed on electronic, print, zestril dosage 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 zestril dosage calls from their patients in despair with increased suicidal ideation. This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of zestril dosage 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 zestril dosage 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 zestril dosage 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 zestril dosage on the episode. Many psychiatrists 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 addition to doing harm and injustice to our zestril dosage patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but zestril dosage 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 zestril dosage 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.

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 zestril dosage 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 - zestril dosage 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage.

This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this 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 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 on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords.

Adverse effect, brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update.

Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al. In the mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic patients, and finally animal ECS studies.

The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time. Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage 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 answer other research questions. These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT.

Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain how ECT acts rather than evidence of 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 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.

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 resolution than what is available today. The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain.

The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT 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 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 be refuted by high-resolution MRI studies.

Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 when Nordanskog et al.

Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al. That there was no volume increase in any part of the brain following ECT.[10] This was quite an exciting finding 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 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 hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 months.[19] This, however, was not associated with 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 these studies by Abbott et al.

In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase in connectivity.[22] In a first of its kind DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus.

The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale 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. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population. It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following ECT in patients with major depressive disorder and 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 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 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 should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals 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 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 levels are usually expected to remain stable.

The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT. Of these, three studies showed that there is no significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite.

However, a direct comparison between these studies is complicated chiefly due to the different ECT protocols, which has been used in these studies. It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations. The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis.

Thus, the authors warn that to conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated 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 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 NAA concentration change in other brain areas have also produced conflicting results. The ACC is another area which has been studied in some detail utilizing the MRSI technique.

In 2003, Pfleiderer et al. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT. This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al.

In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and 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 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 al.

In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al. In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been studied in the amygdala, ACC, and the 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 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. 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 development.

The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect. It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other 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, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration.

However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive domains even showed mild improvement compared to the 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 ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia. It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another area of concern are reports of subjective memory impairment 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 al.

In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail. And, what these studies reveal is rather than damaging the brain, ECT has a neuromodulatory effect on the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this.

These neuromodulatory changes have been localized to the hippocampus, amygdala, and certain other 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 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives neurogenesis, thereby exerting a neuromodulatory effect.

This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the ECT. However, these cannot be construed as brain damage as is usually understood.

Due to the relative scarcity of data that directly examines the question of whether ECT causes brain damage, it is not possible to conclusively answer this question. However, in light of enduring ECT survivor accounts, there is a need to design studies that specifically answer this question.Financial support and 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].

How to cite this article:Singh O P how to get zestril without prescription click here to read. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry how to get zestril without prescription 2020;62:337-8Celebrity suicide is one of the highly publicized events in our country.

Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, the media went into a frenzy as newspapers, news channels, and social media were how to get zestril without prescription full of stories providing minute details of the suicidal act. Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor.

All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and their how to get zestril without prescription 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 how to get zestril without prescription despair with increased suicidal ideation. This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] how to get zestril without prescription 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 how to get zestril without prescription 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 how to get zestril without prescription 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 how to get zestril without prescription houses to comment on the episode. Many psychiatrists 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 how to get zestril without prescription psychiatry and are detrimental to the image of psychiatry in addition to doing harm and injustice to our patients. Hence, the need to formulate a guideline for interaction of psychiatrists with the media is imperative.In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinion about the fitness of Barry Goldwater for presidential candidature. Out of 2417 respondents, 1189 psychiatrists reported him to be mentally unfit while none had actually examined him.[3] This led to the formulation of “The Goldwater Rule” by the American Psychiatric Association in 1973,[4] but we have witnessed the same phenomenon at the time of presidential candidature of Donald Trump.Psychiatrists should be encouraged to interact with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the media” how to get zestril without prescription 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 how to get zestril without prescription psychiatrists should familiarize themselves with these documents. The Press Council guideline is likely to prompt reporters to seek psychiatrists for their expert opinion.

It is useful for them to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as help available.[5]It is about time that the Indian Psychiatric Society formulated its own guidelines laying down the broad principles and boundaries governing the interaction of Indian psychiatrists with the media. Till then, it is desirable to be guided by the following broad principles:It should be assumed that no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not 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 how to get zestril without prescription the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata how to get zestril without prescription - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_816_20Abstract Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage.

This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this 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 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 on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.Keywords.

Adverse effect, brain damage, electroconvulsive therapyHow to cite this article:Jolly AJ, Singh SM. Does electroconvulsive therapy cause brain damage. An update.

Indian J Psychiatry 2020;62:339-53 Introduction Electroconvulsive therapy (ECT) as a modality of treatment for psychiatric disorders has existed at least since 1938.[1] ECT is an effective modality of treatment for various psychiatric disorders. However, from the very beginning, the practice of ECT has also faced resistance from various groups who claim that it is coercive and harmful.[2] While the ethical aspects of the practice of ECT have been dealt with elsewhere, the question of harmfulness or brain damage consequent upon the passage of electric current needs to be examined afresh in light of technological advances and new knowledge.[3]The question whether ECT causes brain damage was reviewed in a holistic fashion by Devanand et al. In the mid-1990s.[4],[5] The authors had attempted to answer this question by reviewing the effect of ECT on the brain in various areas – cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epileptic patients, and finally animal ECS studies.

The authors had concluded that ECT does not produce brain damage.This narrative review aims to update the evidence with regard to whether ECT causes brain damage by reviewing relevant literature from 1994 to the present time. Framing the Question The Oxford Dictionary defines damage as physical harm that impairs the value, usefulness, or normal function of something.[6] Among medical dictionaries, the Peter Collins Dictionary defines damage as harm done to things (noun) or to harm something (verb).[7] Brain damage is defined by the British Medical Association Medical Dictionary as degeneration or death of nerve cells and tracts within the brain that may be localized to a particular area of the brain or diffuse.[8] Going by such a definition, brain damage 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 answer other research questions. These studies have employed the following methods:Structural neuroimaging studiesFunctional neuroimaging studiesMetabolic neuroimaging studiesBody fluid biochemical marker studiesCognitive impairment studies.While the early studies tended to focus more on establishing the safety of ECT and finding out whether ECT causes gross microscopic brain damage, the later studies especially since the advent of advanced neuroimaging techniques have been focusing more on a mechanistic understanding of ECT.

Hence, the primary objective of the later neuroimaging studies has been to look for structural and functional brain changes which might explain how ECT acts rather than evidence of 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 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.

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 resolution than what is available today. The authors concluded that there was no evidence to show that ECT caused any structural damage to the brain.[4] Since then, at least twenty more MRI-based structural neuroimaging studies have studied the effect of ECT on the brain.

The earliest MRI studies in the early 1990s focused on detecting structural damage following ECT. All of these studies were prospective in design, with the first MRI scan done at baseline and a second MRI scan performed post ECT.[9],[11],[12],[13],[41] While most of the studies imaged the patient once around 24 h after receiving ECT, some studies performed multiple post ECT 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 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 be refuted by high-resolution MRI studies.

Nonetheless, one inescapable conclusion of these early studies was that there was no evidence of any gross structural brain changes following administration of ECT. Much later in 2007, Szabo et al. Used diffusion-weighted MRI to image patients in the immediate post ECT period and failed to observe any obvious brain tissue changes following ECT.[17]The next major breakthrough came in 2010 when Nordanskog et al.

Demonstrated that there was a significant increase in the volume of the hippocampus bilaterally following a course of ECT in a cohort of patients with depressive illness.[18] This contradicted the earlier observations by Coffey et al. That there was no volume increase in any part of the brain following ECT.[10] This was quite an exciting finding 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 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 hypothesis. Till date, only one study – Nordanskog et al., 2014 – has followed study patients for a long term – 6 months in their case. And significantly, the authors found out that after increasing immediately following ECT, the hippocampal volume returns back to baseline by 6 months.[19] This, however, was not associated with 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 these studies by Abbott et al.

In 2014 demonstrated that on fMRI, the connectivity between right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized following ECT, and symptom improvement was correlated with an increase in connectivity.[22] In a first of its kind DTI study, Lyden et al. In 2014 demonstrated that fractional anisotropy which is a measure of white matter tract or fiber density is increased post ECT in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left superior longitudinal fasciculus.

The authors suggested that ECT acts to normalize major depressive disorder-related abnormalities in the structural connectivity of the dorsal fronto-limbic pathways.[23] Another DTI study in 2015 constructed large-scale 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. It was found that the medial prefrontal cortex/anterior cingulate cortex (ACC/MPFC) network, MTL network, bilateral thalamus, and left cerebellar regions/precuneus exhibited significant difference between healthy controls and the patient population. It was also demonstrated that administration of ECT leads to significant increase in the network strength of the ACC/MPFC network and the MTL network though the increase in network strength and symptom amelioration were not correlated.[32]Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of brain volume changes – focusing on hippocampal volume increase following ECT in patients with major depressive disorder and 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 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 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 should, however, be weighed against the definition of damage as understood by the scientific medical community and patient population. Neuroanatomical changes associated with effective ECT can be better described as ECT-induced brain neuroplasticity or ECT-induced brain neuromodulation rather than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase-encoding procedure to map the spatial distribution of magnetic resonance (MR) signals 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 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 levels are usually expected to remain stable.

The regions which have been most widely studied in MRSI studies include the bilateral hippocampus and amygdala, dorsolateral prefrontal cortex (DLPFC), and ACC.Till date, five MRSI studies have measured NAA concentration in the hippocampus before and after ECT. Of these, three studies showed that there is no significant change in the NAA concentration in the hippocampus following ECT.[33],[38],[49] On the other hand, two recent studies have demonstrated a statistically significant reduction in NAA concentration in the hippocampus following ECT.[39],[40] The implications of these results are of significant interest to us in answering our titular question. A normal level of NAA following ECT could signify that there is no significant neuronal death or damage following ECT, while a reduction would signal the opposite.

However, a direct comparison between these studies is complicated chiefly due to the different ECT protocols, which has been used in these studies. It must, however, be acknowledged that the three older studies used 1.5 T MRI, whereas the two newer studies used a higher 3 T MRI which offers betters signal-to-noise ratio and hence lesser risk of errors in the measurement of metabolite concentrations. The authors of a study by Njau et al.[39] argue that a change in NAA levels might reflect reversible changes in neural metabolism rather than a permanent change in the number or density of neurons and also that reduced NAA might point to a change in the ratio of mature to immature neurons, which, in fact, might reflect enhanced adult neurogenesis.

Thus, the authors warn that to conclude whether a reduction in NAA concentration is beneficial or harmful would take a simultaneous measurement of cognitive functioning, which was lacking in their study. In 2017, Cano et al. Also demonstrated 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 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 NAA concentration change in other brain areas have also produced conflicting results. The ACC is another area which has been studied in some detail utilizing the MRSI technique.

In 2003, Pfleiderer et al. Demonstrated that there was no significant change in the NAA and Cho levels in the ACC following ECT. This would seem to suggest that there was no neurogenesis or membrane turnover in the ACC post ECT.[36] However, this finding was contested by Merkl et al.

In 2011, who demonstrated that NAA levels were significantly reduced in the left ACC in patients with depression and 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 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 al.

In 2000 demonstrated a significant elevation in Cho levels in B/L hippocampus after ECT, while Jorgensen et al. In 2015 failed to replicate the same finding.[33],[38] Cho levels have also been studied in the amygdala, ACC, and the 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 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. 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 development.

The most prominent among these is brain-derived neurotrophic factor (BDNF) which plays an important role in neuronal survival, plasticity, and migration.[50] A neurotrophic theory of mood disorders was suggested which hypothesized that depressive disorders are associated with a decreased expression of BDNF in the limbic structures, resulting in the atrophy of these structures.[51] It was also postulated that antidepressant treatment has a neurotrophic effect which reverses the neuronal cell loss, thereby producing a therapeutic effect. It has been well established that BDNF is decreased in mood disorders.[52] It has also been shown that clinical improvement of depression is associated with increase in BDNF levels.[53] Thus, serum BDNF levels have been tentatively proposed as a biomarker for treatment response in depression. Recent meta-analytic evidence has shown that ECT is associated with significant increase in serum BDNF levels in patients with major depressive disorder.[54] Considering that BDNF is a potent stimulator of neurogenesis, the elevation of serum BDNF levels following ECT lends further credence to the theory that ECT leads to neurogenesis in the hippocampus and other 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, visual episodic memory, spatial problem-solving, executive functioning, and intellectual ability. The authors concluded that administration of ECT for depression is associated with significant cognitive impairment in the first few days after ECT administration.

However, it was also seen that impairment in cognitive functioning resolved within a span of 2 weeks and thereafter, a majority of cognitive domains even showed mild improvement compared to the 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 ECT. This is particularly unfortunate considering that it is memory impairment – particularly retrograde amnesia which has received the most attention.[59] In addition, reports of catastrophic retrograde amnesia have been repeatedly held up as sensational evidence of the lasting brain damage produced by ECT.[59] Admittedly, studies on retrograde amnesia are fewer and less conclusive than on anterograde amnesia.[60],[61] At present, the results are conflicting, with some studies finding some impairment in retrograde memory – particularly autobiographical retrograde memory up to 6 months after ECT.[62],[63],[64],[65] However, more recent studies have failed to support this finding.[66],[67] While they do demonstrate an impairment in retrograde memory immediately after ECT, it was seen that this deficit returned to pre-ECT levels within a span of 1–2 months and improved beyond baseline performance at 6 months post ECT.[66] Adding to the confusion are numerous factors which confound the assessment of retrograde amnesia. It has been shown that depressive symptoms can produce significant impairment of retrograde memory.[68],[69] It has also been demonstrated that sine-wave ECT produces significantly more impairment of retrograde memory as compared to brief-pulse ECT.[70] However, from the 1990s onward, sine-wave ECT has been completely replaced by brief-pulse ECT, and it is unclear as to the implications of cognitive impairment from the sine-wave era in contemporary ECT practice.Another area of concern are reports of subjective memory impairment 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 al.

In 1994 since which time our understanding of ECT has grown substantially, helped particularly by the advent of modern-day neuroimaging techniques which we have reviewed in detail. And, what these studies reveal is rather than damaging the brain, ECT has a neuromodulatory effect on the brain. The various lines of evidence – structural neuroimaging studies, functional neuroimaging studies, neurochemical and metabolic studies, and serum BDNF studies all point toward this.

These neuromodulatory changes have been localized to the hippocampus, amygdala, and certain other 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 weeks. Perhaps, the single-most important unaddressed concern is retrograde amnesia, which has been shown to persist for up to 2 months post ECT. In this regard, the recent neurometabolic studies have offered a tentative mechanism of action of ECT, producing a transient inflammation in the limbic cortex, which, in turn, drives neurogenesis, thereby exerting a neuromodulatory effect.

This hypothesis would explain both the cognitive adverse effects of ECT – due to the transient inflammation – and the long-term improvement in mood – neurogenesis in the hippocampus. Although unproven at present, such a hypothesis would imply that cognitive impairment is tied in with the mechanism of action of ECT and not an indicator of damage to the brain produced by ECT.The review of literature suggests that ECT does cause at least structural and functional changes in the brain, and these are in all probability related to the effects of the ECT. However, these cannot be construed as brain damage as is usually understood.

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

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Acta Psychiatr Scand 2018;138:180-95. 45.Oltedal L, Narr KL, Abbott C, Anand A, Argyelan M, Bartsch H, et al. Volume of the human hippocampus and clinical response following electroconvulsive therapy.

Biol Psychiatry 2018;84:574-81. 46.Breggin PR. Brain-Disabling Treatments in Psychiatry.

Drugs, Electroshock, and the Role of the FDA. New York. Springer Pub.

Co.. 1997. 47.Posse S, Otazo R, Dager SR, Alger J.

MR spectroscopic imaging. Principles and recent advances. J Magn Reson Imaging 2013;37:1301-25.

48.Simmons ML, Frondoza CG, Coyle JT. Immunocytochemical localization of N-acetyl-aspartate with monoclonal antibodies. Neuroscience 1991;45:37-45.

49.Obergriesser T, Ende G, Braus DF, Henn FA. Long-term follow-up of magnetic resonance-detectable choline signal changes in the hippocampus of patients treated with electroconvulsive therapy. J Clin Psychiatry 2003;64:775-80.

50.Bramham CR, Messaoudi E. BDNF function in adult synaptic plasticity. The synaptic consolidation hypothesis.

Prog Neurobiol 2005;76:99-125. 51.Duman RS, Monteggia LM. A neurotrophic model for stress-related mood disorders.

Biol Psychiatry 2006;59:1116-27. 52.Bocchio-Chiavetto L, Bagnardi V, Zanardini R, Molteni R, Nielsen MG, Placentino A, et al. Serum and plasma BDNF levels in major depression.

A replication study and meta-analyses. World J Biol Psychiatry 2010;11:763-73. 53.Brunoni AR, Lopes M, Fregni F.

A systematic review and meta-analysis of clinical studies on major depression and BDNF levels. Implications for the role of neuroplasticity in depression. Int J Neuropsychopharmacol 2008;11:1169-80.

54.Rocha RB, Dondossola ER, Grande AJ, Colonetti T, Ceretta LB, Passos IC, et al. Increased BDNF levels after electroconvulsive therapy in patients with major depressive disorder. A meta-analysis study.

J Psychiatr Res 2016;83:47-53. 55.UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders.

A systematic review and meta-analysis. Lancet 2003;361:799-808. 56.57.Semkovska M, McLoughlin DM.

Objective cognitive performance associated with electroconvulsive therapy for depression. A systematic review and meta-analysis. Biol Psychiatry 2010;68:568-77.

58.Tulving E, Madigan SA. Memory and verbal learning. Annu Rev Psychol 1970;21:437-84.

59.Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy. Systematic review.

BMJ 2003;326:1363. 60.Semkovska M, McLoughlin DM. Measuring retrograde autobiographical amnesia following electroconvulsive therapy.

Historical perspective and current issues. J ECT 2013;29:127-33. 61.Fraser LM, O'Carroll RE, Ebmeier KP.

The effect of electroconvulsive therapy on autobiographical memory. A systematic review. J ECT 2008;24:10-7.

62.Squire LR, Chace PM. Memory functions six to nine months after electroconvulsive therapy. Arch Gen Psychiatry 1975;32:1557-64.

63.Squire LR, Slater PC. Electroconvulsive therapy and complaints of memory dysfunction. A prospective three-year follow-up study.

Br J Psychiatry 1983;142:1-8. 64.Squire LR, Slater PC, Miller PL. Retrograde amnesia and bilateral electroconvulsive therapy.

Long-term follow-up. Arch Gen Psychiatry 1981;38:89-95. 65.Squire LR, Wetzel CD, Slater PC.

Memory complaint after electroconvulsive therapy. Assessment with a new self-rating instrument. Biol Psychiatry 1979;14:791-801.

66.Calev A, Nigal D, Shapira B, Tubi N, Chazan S, Ben-Yehuda Y, et al. Early and long-term effects of electroconvulsive therapy and depression on memory and other cognitive functions. J Nerv Ment Dis 1991;179:526-33.

67.Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-34.

68.Abrams R. Does brief-pulse ECT cause persistent or permanent memory impairment?. J ECT 2002;18:71-3.

69.Peretti CS, Danion JM, Grangé D, Mobarek N. Bilateral ECT and autobiographical memory of subjective experiences related to melancholia. A pilot study.

J Affect Disord 1996;41:9-15. 70.Weiner RD, Rogers HJ, Davidson JR, Squire LR. Effects of stimulus parameters on cognitive side effects.

Ann N Y Acad Sci 1986;462:315-25. 71.Prudic J, Peyser S, Sackeim HA. Subjective memory complaints.

A review of patient self-assessment of memory after electroconvulsive therapy. J ECT 2000;16:121-32. 72.Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, et al.

Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993;328:839-46. 73.Frith CD, Stevens M, Johnstone EC, Deakin JF, Lawler P, Crow TJ.

Effects of ECT and depression on various aspects of memory. Br J Psychiatry 1983;142:610-7. 74.Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, et al.

Efficacy and cognitive effects of right unilateral electroconvulsive therapy. J ECT 2000;16:370-9. 75.Coleman EA, Sackeim HA, Prudic J, Devanand DP, McElhiney MC, Moody BJ.

Subjective memory complaints prior to and following electroconvulsive therapy. Biol Psychiatry 1996;39:346-56. 76.Berggren Š, Gustafson L, Höglund P, Johanson A.

A long-term longitudinal follow-up of depressed patients treated with ECT with special focus on development of dementia. J Affect Disord 2016;200:15-24. 77.Brodaty H, Hickie I, Mason C, Prenter L.

A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord 2000;60:101-11. 78.Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB.

Electroconvulsive therapy and risk of dementia in patients with affective disorders. A cohort study. Lancet Psychiatry 2018;5:348-56.

Correspondence Address:Dr. Shubh Mohan SinghDepartment of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_239_19 Tables [Table 1], [Table 2].

What side effects may I notice from Zestril?

Side effects that you should report to your doctor or health care professional as soon as possible:

  • abdominal pain with or without nausea or vomiting
  • allergic reactions like skin rash or hives, swelling of the hands, feet, face, lips, throat, or tongue
  • dark urine
  • difficulty breathing
  • dizzy, lightheaded or fainting spell
  • fever or sore throat
  • irregular heart beat, chest pain
  • pain or difficulty passing urine
  • redness, blistering, peeling or loosening of the skin, including inside the mouth
  • unusually weak
  • yellowing of the eyes or skin

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

  • change in taste
  • cough
  • decreased sexual function or desire
  • headache
  • sun sensitivity
  • tiredness

This list may not describe all possible side effects.

Generic zestril cost

Sport is https://www.voiture-et-handicap.fr/buy-zestril-canada/ predicated on the idea generic zestril cost of victors emerging from a level playing field. All ethically informed evaluate practices are like this. They require an generic zestril cost equality of respect, consideration, and opportunity, while trying to achieve substantively unequal outcomes. For instance. Limited resources mean that physicians must treat some patients and not others, while still treating them with equal respect.

Examiners must pass some students and not generic zestril cost others, while still giving their work equal consideration. Employers may only be able to hire one applicant, while still being required to treat all applicants fairly, and so on. The 800 m is meant to generic zestril cost be one of these practices. A level and equidistance running track from which one victor is intended to emerge. The case of Caster Semenya raises challenging questions about what makes level-playing-fields level, questions that extend beyond any given playing field.In the Feature Article for this issue Loland provides us with new and engaging reasons to support of the Court of Arbitration for Sport (CAS) decision in the Casta Semenya case.

The impact of the CAS decision requires Casta Semenya to supress her naturally occurring testosterone if she is to compete in an international generic zestril cost athletics events. The Semenya case is described by Loland as creating a ‘dilemma of rights’.i The dilemma lies in the choice between ‘the right of Semenya to compete in sport according to her legal sex and gender identity’ and ‘the right of other athletes within the average female testosterone range to compete under fair conditions’ (see footnote i).No one denies the importance of Semenya’s right. As Carpenter explains, ‘even where inconvenient, sex assigned at birth should always be respected unless an individual seeks otherwise’.2 Loland’s conclusions, Carpenter argues, ‘support a convenience-based approach to classification of sex where choices about the status of people with intersex variations are made by others according to their interests at that time’ (see footnote ii) generic zestril cost. Carpenter then further explains how the CAS decision is representative of ‘systemic forms of discrimination and human rights violations’ and provides no assistance in ‘how we make the world more hospitable and more accepting of difference’ (see footnote ii).What is therefore at issue is the existence of the second right. Let me explain how Loland constructs it.

The background principle is the principle of fair equality of opportunity, which requires that generic zestril cost ‘individuals with similar endowments and talents and similar ambitions should be given similar opportunities and roughly equivalent prospects for competitive success’(see footnote i). This principle reflects, according to Loland, a deeper deontological right of respect and fair treatment. As we can appreciate, when it comes to the principle of fair equality of opportunity, a lot turns on what counts as ‘similar’ (or sufficiently different) endowments and talents and what counts as ‘similar’ (or sufficiently different) opportunities and prospects for success.For Loland, ‘dynamic inequalities’ concern differences in capabilities (such as strength, speed, and endurance, and in technical and tactical skills) that can be ‘cultivated by hard work and effort’ (see footnote i). These are capabilities that generic zestril cost are ‘relevant’ and therefore permit a range differences between otherwise ‘similar’ athletes. €˜Stable inequalities’ are characterises (such as in age, sex, body size, and disability/ability) are ‘not-relevant’ and therefore require classification to ensure that ‘similar’ athletes are given ‘roughly equivalent prospects for success’.

It follows for Loland that athletes with ‘46 XY DSD conditions (and not for individuals with normal female XX chromosones), with testosterone levels above five nanomoles per litre blood (nmol/L), and who experience a ‘material androgenizing effect’’ benefit generic zestril cost from a stable inequality (see footnote i). Hence, the ‘other athletes within the average female testosterone range’ therefore have a right not to compete under conditions of stable inequality. The solution, according to Knox and Anderson, lies in more nuance classifications. Commenting in (qualified) support of Loland, they suggest that ‘classification according to sex alone is no longer adequate’.3 Instead, ‘all athletes would be categorised, making classification the norm’ (see footnote iii).However, as we have just seen, Loland’s distinction between stable and dynamic inequalities depends on their ‘relevance’, and ‘relevance’ is generic zestril cost a term that does not travel alone. Something is relevant (or irrelevant) only in relation to the value, purpose, or aim, of some practice.

One interpretation (which I take Loland to be saying) is that strength, speed, and endurance (and generic zestril cost so on) are ‘relevant’ to ‘performance outcomes’. This can be misleading. Both dynamic and stable inequalities are relevant to (ie, can have an impact on) an athletic performance. Is a question of whether we generic zestril cost ought to permit them to have an impact. The temptation is then to say that dynamic inequalities are relevant (and stable inequalities are irrelevant) where the aim is ‘respect and fair treatment’.

But here the snake begins to eat its tail (the principle of fair treatment requires sufficiently similar prospects for success >similar prospects for success require only dynamic inequalities>dynamic inequalities are capabilities that are permitted by the principle of fair treatment).In order to determine questions of relevance, we need to identify the value, purpose, or aim, of the social practice in question. If the aim of an athletic event is to have a victor emerge from a completely level playing field, then, as Chambers notes, socioeconomic inequalities are a larger affront to fair treatment than athletes with 46 XY DSD generic zestril cost conditions.4 If the aim is to have a victor emerge from completely level hormonal playing field then ‘a man with low testosterone levels is unfairly disadvantaged against a man whose natural levels are higher, and so men’s competitions are unfair’ (see footnote iv). Or, at least very high testosterone males should be on hormone suppressants in order to give the ‘average’ competitor a ‘roughly equivalent prospect for competitive success’.The problem is that we are not interested in the average competitor. We are interested in the exceptional among us generic zestril cost. Unless, it is for light relief.

In every Olympiad there is the observation that, in every Olympic event, one average person should be included in the competition for the spectators’ reference. The humour lies in the absurd scenarios that would follow, whether it be the 100 m sprint, high jump, or synchronised swimming generic zestril cost. Great chasms of natural ability would be laid bare, the results of a lifetime of training and dedication would be even clearer to see, and the last place result would be entirely predictable. But note how these generic zestril cost are different attributes. While we may admire Olympians, it is unclear whether it is because of their God-given ability, their grit and determination, or their role in the unpredictable theatre of sport.

If sport is a worthwhile social practice, we need to start spelling out its worth. Without doing so, we are unable to identify what capabilities are ‘relevant’ or ‘irrelevant’ to its aims, purpose generic zestril cost or value. And until we can explain why one naturally occurring capability is ‘irrelevant’ to the aims, purposes, or values, of sport, while the remainder of them are relevant, I can only identify one right in play in the Semenya case.IntroductionSince the start of the COVID-19 pandemic, many medical systems have needed to divert routine services in order to support the large number of patients with acute COVID-19 disease. For example, in generic zestril cost the National Health Service (NHS) almost all elective surgery has been postponed1 and outpatient clinics have been cancelled or conducted on-line treatment regimens for many forms of cancer have changed2. This diversion inevitably reduces availability of routine treatments for non-COVID-19-related illness.

Even urgent treatments have needed to be modified. Patients with generic zestril cost acute surgical emergencies such as appendicitis still present for care, cancers continue to be discovered in patients, and may require urgent management. Health systems are focused on making sure that these urgent needs are met. However, to achieve this goal, many patients are offered treatments that deviate from standard, non-pandemic management.Deviations from standard management are required for multiple factors such as:Limited resources (staff and equipment reallocated).Risk of nosocomial acquired infection in high-risk patients.Increased risk for medical staff to deliver treatments due to aerosolisation1.Treatments requiring intensive care therapy that is in limited availability.Operative procedures that are long and difficult or that are technically challenging if conducted in personal protective equipment. The outcomes from such procedures may be worse than in normal circumstances.Treatments that render patients more susceptible to COVID-19 disease, for example chemotherapy.There are many instances of compromise, but some generic zestril cost examples that we are aware of include open appendectomy rather than laparoscopy to reduce risk of aerosolisation3 and offering a percutaneousCoronary intervention (PCI) rather than coronary artery bypass grafting (CABG) for coronary artery disease, to reduce need for intensive care.

Surgery for cancers ordinarily operated on urgently maybe deferred for up to 3 months4 and surgery might be conducted under local anaesthesia that would typically have merited a general anaesthetic (both to reduce the aerosol risk of General anaesthesia, and because of relative lack of anaesthetists).The current emergency offers a unique difficulty. A significant number of treatments with proven benefit might be unavailable to patients generic zestril cost while those alternatives that are available are not usually considered best practice and might be actually inferior. In usual circumstances, where two treatment options for a particular problem are considered appropriate, the decision of which option to pursue would often depend on the personal preference of the patient.But during the pandemic what is ethically and legally required of the doctor or medical professional informing patients about treatment and seeking their consent?. In particular, do health professionals need to make patients aware of the usual forms of treatment that they are not being offered in the current setting?. We consider two theoretical case examples:Case 1Jenny2 is a model in her mid-20s generic zestril cost who presents to hospital at the peak of the COVID-19 pandemic with acute appendicitis.

Her surgeon, Miss Schmidt, approaches Jenny to obtain consent for an open appendectomy. Miss Schmidt explains the risks of the operative procedure, and the alternative generic zestril cost of conservative management (with intravenous antibiotics). Jenny consents to the procedure. However, she develops a postoperative wound infection and an unsightly scar. She does some research and discovers generic zestril cost that a laparoscopic procedure would ordinarily have been performed and would have had a lower chance of wound infection.

She sues Miss Schmidt and the hospital trust where she was treated.Case 2June2s a retired teacher in her early 70s who has well-controlled diabetes and hypertension. She is active and runs a local food bank. Immediately prior to the pandemic lockdown in the UK June generic zestril cost had an episode of severe chest pain and investigations revealed that she has had a non-ST elevation myocardial infarction. The cardiothoracic surgical team recommends that June undergo a PCI although normally her pattern of coronary artery disease would be treated by CABG. When the cardiologist explains that surgery would be normally offered in this situation, and is theoretically superior to PCI, June’s husband becomes angry and demands that June is listed for surgery.In favour generic zestril cost of non-disclosureIt might appear at first glance that doctors should obviously inform Jenny and June about the usual standard of care.

After all, consent cannot be informed if crucial information is lacking. However, one reason that this may be called into question is that it is not immediately clear how it benefits a patient to be informed about alternatives that are not actually available?. In generic zestril cost usual circumstances, doctors are not obliged to inform patients about treatments that are performed overseas but not in the UK. In the UK, for example, there is a rigorous process for assessment of go to this website new treatments (not including experimental therapies). Some treatments that are available in other jurisdictions have not been deemed by the National Institute for Health and Care Excellence (NICE) to be sufficiently beneficial and cost-effective to be offered generic zestril cost by the NHS.

It is hard to imagine that a health professional would be found negligent for not discussing with a patient a treatment that NICE has explicitly rejected. The same might apply for novel therapies that are currently unfunded pending formal evaluation by NICE.Of course, the difference is that the treatments we are discussing have been proven (or are believed) to be beneficial and would normally be provided. The Montgomery Ruling of 2015 in the generic zestril cost UK established that patients must be informed of material risks of treatment and reasonable alternatives to treatment. The Bayley –v- George Eliot Hospital NHS Trust5case established that those reasonable alternative treatments must be ‘appropriate treatment’ not just a ‘possible treatment’6. In the current crisis, many previously standard treatments are no longer appropriate given generic zestril cost the restrictions outlined.

In other circumstances they are appropriate. During a pandemic they are no longer appropriate, even if they become appropriate again at some unknown time in the future.In both ethical and legal terms, it is widely accepted that, for consent to be valid, if must be given voluntarily by a person who has capacity to consent and who understands the nature and risks of the treatment. A failure to obtain valid consent, generic zestril cost or performing interventions in the absence of consent, could result in criminal proceedings for assault. Failing to provide adequate information in the consent process could support a claim of negligence. Ethically, adequate information about treatments is essential for the patient to enable them to weigh up options and decide which treatments they wish to undertake.

However, information about unavailable treatments arguably does not help the patient make an informed decision because it does not give them information that is relevant generic zestril cost to consenting or to refusal of treatment that is actually available. If Miss Schmidt had given Jenny information about the relative benefits of laparoscopic appendectomy, that could not have helped Jenny’s decision to proceed with surgery. Her available generic zestril cost choices were open appendectomy or no surgery. Moreover, as the case of June highlights, providing information about alternatives may lead them to desire or even demand those alternative options. This could cause distress both to the patient and the health professional (who is unable to acquiesce).Consideration might also be paid to the effect on patients of disclosure.

How would it affect a patient with newly diagnosed cancer to tell them that an alternative, perhaps better therapy, might be routinely available generic zestril cost in usual circumstances but is not available now?. There is provision in the Montgomery Ruling, in rare circumstances, for therapeutic exception. That is, if information is significantly detrimental to the health generic zestril cost of a patient it might be omitted. We could imagine a version of the case where Jenny was so intensely anxious about the proposed surgery that her surgeon comes to a sincere belief that discussion of the laparoscopic alternative would be extremely distressing or might even lead her to refuse surgery. In most cases, though, it would be hard to be sure that the risks of disclosing alternative (non-available) treatments would be so great that non-disclosure would be justified.In favour of disclosureIn the UK, professional guidance issued by the GMC (General Medical Council) requires doctors to take a personalised approach to information sharing about treatments by sharing ‘with patients the information they want or need in order to make decisions’.

The Montgomery judgement of 20157 broadly endorsed the position of the GMC, requiring patients generic zestril cost to be told about any material risks and reasonable alternatives relevant to the decision at hand. The Supreme Court clarifies that materiality here should be judged by reference to a new two-limbed test founded on the notions of the ‘reasonable person in the patient’s position’ and the ‘particular patient’. One practical test might be for the clinician to ask themselves whether patients in general, or this particular patient might wish to know about alternative forms of treatment that would usually be offered.The GMC has recently produced pandemic-specific guidance8 on consent and decision-making, but this guidance is focused on managing consent in COVID-19-related interventions. While the GMC takes the view that its consent guidelines continue to apply as far as is practical, it also notes that the patient is enabled to consider the ‘reasonable alternatives’, and that the doctor is ‘open and honest with patients about the decision-making process and the criteria generic zestril cost for setting priorities in individual cases’.In some situations, there might be the option of delaying treatment until later. When other surgical procedures are possible.

In that setting, it would be important to ensure that the patient is aware generic zestril cost of those future options (including the risks of delay). For example, if Jenny had symptomatic gallstones, her surgeons might be offering an open cholecystectomy now or the possibility of a laparoscopic surgery at some later point. Understanding the full options open to her now and in the future may have considerable influence on Jenny’s decision. Likewise, if June is aware that she is not being generic zestril cost offered standard treatment she may wish to delay treatment of her atherosclerosis until a later date. Of course, such a delay might lead to greater harm overall.

However, it would be ethically permissible to delay treatment if that was the patient’s informed choice (just as it would be permissible for the patient to refuse treatment altogether).In the appendicitis case, Jenny does not have the option for delaying her treatment, but the choice generic zestril cost for June is more complicated, between immediate PCI which is a second-best treatment versus waiting for standard therapy. Immediate surgery also raises a risk of acquiring nosocomial COVID-19 infection and June is in an age group and has comorbidities that put her at risk of severe COVID-19 disease. Waiting for surgery leaves June at risk of sudden death. For an active generic zestril cost and otherwise well patient with coronary disease like June, PCI procedure is not as good a treatment as CABG and June might legitimately wish to take her chances and wait for the standard treatment. The decision to operate or wait is a balance of risks that only June is fully able to make.

Patients in this scenario will generic zestril cost take different approaches. Patients will need different amounts of information to form their decisions, many patients will need as much information as is available including information about procedures not currently available to make up their mind.June’s husband insists that she should receive the best treatment, and that she should therefore be listed for CABG. Although this treatment would appear to be in June’s best interests, and would respect her autonomy, those ethical considerations are potentially outweighed by distributive justice. The COVID-19 pandemic of generic zestril cost 2020 is being characterised by limitations. Liberties curtailed and choices restricted, this is justified by a need to protect healthcare systems from demand exceeding availability.

While resource allocation is always a relevant ethical concern in publicly funded healthcare systems, it is a dominant concern in a setting where there is a high demand for medical care and scare resources.It is well established that competent adult patients can consent to or refuse medical treatment but they cannot demand that health professionals provide treatments that are contrary to their professional judgement or (even more importantly) would consume scarce healthcare resources. In June’s case, agreeing to perform CABG at a time when large numbers of patients are critically ill with COVID-19 might mean that another patient is denied access to intensive care (and even dies as generic zestril cost a result). Of course, it may be that there are actually available beds in intensive care, and June’s operation would not directly lead to denial of treatment for another patient. However, that does not automatically mean generic zestril cost that surgery must proceed. The hospital may have been justified in making a decision to suspend some forms of cardiac surgery.

That could be on the basis of the need to use the dedicated space, staff and equipment of the cardiothoracic critical care unit for patients with COVID-19. Even if all that physical space is not currently occupied if may not be feasible or practical to try to simultaneously accommodate some non-COVID-19 patients generic zestril cost. (There would be a risk that June would contract COVID-19 postoperatively and end up considerably worse off than she would have been if she had instead received PCI.) Moreover, it seems problematic for individual patients to be able to circumvent policies about allocation of resources purely on the basis that they stand to be disadvantaged by the policy.Perhaps the most significant benefit of disclosure of non-options is transparency and honesty. We suggest that the main reason why Miss Schmidt ought to have included discussion of the laparoscopic generic zestril cost alternative is so that Jenny understands the reasoning behind the decision. If Miss Schmidt had explained to Jenny that in the current circumstances laparoscopic surgery has been stopped, that might have helped her to appreciate that she was being offered the best available management.

It might have enabled a frank discussion about the challenges faced by health professionals in the context of the pandemic and the inevitable need for compromise. It may have avoided awkward discussions later after Jenny developed her complication.Transparent disclosure should generic zestril cost not mean that patients can demand treatment. But it might mean that patients could appeal against a particular policy if they feel that it has been reached unfairly, or applied unfairly. For example, if June became aware that some patients were still being offered CABG, she might (or might not) be justified in appealing against the decision not to offer it to her. Obviously such an appeal would only generic zestril cost be possible if the patient were aware of the alternatives that they were being denied.For patients faced by decisions such as that faced by June, balancing risks of either option is highly personal.

Individuals need to weigh up these decisions for them and require all of the information available to do so. Some information is readily available, for example, the rate of infection for Jenny and the risk of death without treatment for generic zestril cost June. But other risks are unknown, such as the risk of acquiring nosocomial infection with COVID-19. Doctors might feel discomfort talking about unquantifiable risks, but we argue that it is important that the patient has all available information to weigh up options for them, including information that is unknown.ConclusionIn a pandemic, as in other times, doctors should ensure that they offer appropriate medical treatment, based on the needs of an individual. They should generic zestril cost aim to provide available treatment that is beneficial and should not offer treatment that is unavailable or contrary to the patient best interests.

It is ethical. Indeed it is vital within a public healthcare system, to generic zestril cost consider distributive justice in the allocation of treatment. Where treatment is scarce, it may not be possible or appropriate to offer to patients some treatments that would be beneficial and desired by them.Informed consent needs to be individualised. Doctors are obliged to tailor their information to the needs of an individual. We suggest that in the current climate this should include, for most generic zestril cost patients, a nuanced open discussion about alternative treatments that would have been available to them in usual circumstances.

That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing. However, transparency and honesty will usually be the best policy..

Sport is how to get zestril without prescription predicated on the idea of victors emerging from a level playing field https://www.voiture-et-handicap.fr/buy-zestril-canada/. All ethically informed evaluate practices are like this. They require an equality of how to get zestril without prescription respect, consideration, and opportunity, while trying to achieve substantively unequal outcomes. For instance. Limited resources mean that physicians must treat some patients and not others, while still treating them with equal respect.

Examiners must pass some students and not others, while still giving their work how to get zestril without prescription equal consideration. Employers may only be able to hire one applicant, while still being required to treat all applicants fairly, and so on. The 800 m is meant how to get zestril without prescription to be one of these practices. A level and equidistance running track from which one victor is intended to emerge. The case of Caster Semenya raises challenging questions about what makes level-playing-fields level, questions that extend beyond any given playing field.In the Feature Article for this issue Loland provides us with new and engaging reasons to support of the Court of Arbitration for Sport (CAS) decision in the Casta Semenya case.

The impact of the CAS how to get zestril without prescription decision requires Casta Semenya to supress her naturally occurring testosterone if she is to compete in an international athletics events. The Semenya case is described by Loland as creating a ‘dilemma of rights’.i The dilemma lies in the choice between ‘the right of Semenya to compete in sport according to her legal sex and gender identity’ and ‘the right of other athletes within the average female testosterone range to compete under fair conditions’ (see footnote i).No one denies the importance of Semenya’s right. As Carpenter explains, ‘even where inconvenient, sex assigned at birth should always be respected unless an individual seeks otherwise’.2 Loland’s conclusions, Carpenter argues, ‘support a convenience-based approach to classification of sex where choices about the status of people with intersex variations are made by others according how to get zestril without prescription to their interests at that time’ (see footnote ii). Carpenter then further explains how the CAS decision is representative of ‘systemic forms of discrimination and human rights violations’ and provides no assistance in ‘how we make the world more hospitable and more accepting of difference’ (see footnote ii).What is therefore at issue is the existence of the second right. Let me explain how Loland constructs it.

The background principle is the principle of fair equality of opportunity, which requires that ‘individuals how to get zestril without prescription with similar endowments and talents and similar ambitions should be given similar opportunities and roughly equivalent prospects for competitive success’(see footnote i). This principle reflects, according to Loland, a deeper deontological right of respect and fair treatment. As we can appreciate, when it comes to the principle of fair equality of opportunity, a lot turns on what counts as ‘similar’ (or sufficiently different) endowments and talents and what counts as ‘similar’ (or sufficiently different) opportunities and prospects for success.For Loland, ‘dynamic inequalities’ concern differences in capabilities (such as strength, speed, and endurance, and in technical and tactical skills) that can be ‘cultivated by hard work and effort’ (see footnote i). These are capabilities that are ‘relevant’ and therefore permit a range differences between otherwise ‘similar’ athletes how to get zestril without prescription. €˜Stable inequalities’ are characterises (such as in age, sex, body size, and disability/ability) are ‘not-relevant’ and therefore require classification to ensure that ‘similar’ athletes are given ‘roughly equivalent prospects for success’.

It follows for Loland that athletes with ‘46 XY DSD conditions (and not for individuals with normal female XX chromosones), with testosterone levels above five nanomoles per litre blood how to get zestril without prescription (nmol/L), and who experience a ‘material androgenizing effect’’ benefit from a stable inequality (see footnote i). Hence, the ‘other athletes within the average female testosterone range’ therefore have a right not to compete under conditions of stable inequality. The solution, according to Knox and Anderson, lies in more nuance classifications. Commenting in (qualified) support of Loland, they suggest that ‘classification according to sex alone is no longer adequate’.3 Instead, ‘all athletes would be categorised, making classification the norm’ (see footnote iii).However, as we have just seen, Loland’s distinction between stable and dynamic inequalities depends on their ‘relevance’, and ‘relevance’ how to get zestril without prescription is a term that does not travel alone. Something is relevant (or irrelevant) only in relation to the value, purpose, or aim, of some practice.

One interpretation (which I take Loland to be saying) is that strength, speed, and endurance (and so on) are how to get zestril without prescription ‘relevant’ to ‘performance outcomes’. This can be misleading. Both dynamic and stable inequalities are relevant to (ie, can have an impact on) an athletic performance. Is a question of whether we ought to permit them to have how to get zestril without prescription an impact. The temptation is then to say that dynamic inequalities are relevant (and stable inequalities are irrelevant) where the aim is ‘respect and fair treatment’.

But here the snake begins to eat its tail (the principle of fair treatment requires sufficiently similar prospects for success >similar prospects for success require only dynamic inequalities>dynamic inequalities are capabilities that are permitted by the principle of fair treatment).In order to determine questions of relevance, we need to identify the value, purpose, or aim, of the social practice in question. If the aim of an athletic event is to have a victor how to get zestril without prescription emerge from a completely level playing field, then, as Chambers notes, socioeconomic inequalities are a larger affront to fair treatment than athletes with 46 XY DSD conditions.4 If the aim is to have a victor emerge from completely level hormonal playing field then ‘a man with low testosterone levels is unfairly disadvantaged against a man whose natural levels are higher, and so men’s competitions are unfair’ (see footnote iv). Or, at least very high testosterone males should be on hormone suppressants in order to give the ‘average’ competitor a ‘roughly equivalent prospect for competitive success’.The problem is that we are not interested in the average competitor. We are how to get zestril without prescription interested in the exceptional among us. Unless, it is for light relief.

In every Olympiad there is the observation that, in every Olympic event, one average person should be included in the competition for the spectators’ reference. The humour lies in the absurd scenarios how to get zestril without prescription that would follow, whether it be the 100 m sprint, high jump, or synchronised swimming. Great chasms of natural ability would be laid bare, the results of a lifetime of training and dedication would be even clearer to see, and the last place result would be entirely predictable. But note how to get zestril without prescription how these are different attributes. While we may admire Olympians, it is unclear whether it is because of their God-given ability, their grit and determination, or their role in the unpredictable theatre of sport.

If sport is a worthwhile social practice, we need to start spelling out its worth. Without doing so, we are unable to identify what capabilities are ‘relevant’ or ‘irrelevant’ how to get zestril without prescription to its aims, purpose or value. And until we can explain why one naturally occurring capability is ‘irrelevant’ to the aims, purposes, or values, of sport, while the remainder of them are relevant, I can only identify one right in play in the Semenya case.IntroductionSince the start of the COVID-19 pandemic, many medical systems have needed to divert routine services in order to support the large number of patients with acute COVID-19 disease. For example, in the National Health Service (NHS) almost all elective surgery has been postponed1 and outpatient clinics how to get zestril without prescription have been cancelled or conducted on-line treatment regimens for many forms of cancer have changed2. This diversion inevitably reduces availability of routine treatments for non-COVID-19-related illness.

Even urgent treatments have needed to be modified. Patients with acute surgical emergencies such as appendicitis still present for care, how to get zestril without prescription cancers continue to be discovered in patients, and may require urgent management. Health systems are focused on making sure that these urgent needs are met. However, to achieve this goal, many patients are offered treatments that deviate from standard, non-pandemic management.Deviations from standard management are required for multiple factors such as:Limited resources (staff and equipment reallocated).Risk of nosocomial acquired infection in high-risk patients.Increased risk for medical staff to deliver treatments due to aerosolisation1.Treatments requiring intensive care therapy that is in limited availability.Operative procedures that are long and difficult or that are technically challenging if conducted in personal protective equipment. The outcomes from such procedures may be worse than in normal circumstances.Treatments how to get zestril without prescription that render patients more susceptible to COVID-19 disease, for example chemotherapy.There are many instances of compromise, but some examples that we are aware of include open appendectomy rather than laparoscopy to reduce risk of aerosolisation3 and offering a percutaneousCoronary intervention (PCI) rather than coronary artery bypass grafting (CABG) for coronary artery disease, to reduce need for intensive care.

Surgery for cancers ordinarily operated on urgently maybe deferred for up to 3 months4 and surgery might be conducted under local anaesthesia that would typically have merited a general anaesthetic (both to reduce the aerosol risk of General anaesthesia, and because of relative lack of anaesthetists).The current emergency offers a unique difficulty. A significant number of treatments with proven benefit might be unavailable to patients while those alternatives that are available are not usually considered best practice and might be actually inferior how to get zestril without prescription. In usual circumstances, where two treatment options for a particular problem are considered appropriate, the decision of which option to pursue would often depend on the personal preference of the patient.But during the pandemic what is ethically and legally required of the doctor or medical professional informing patients about treatment and seeking their consent?. In particular, do health professionals need to make patients aware of the usual forms of treatment that they are not being offered in the current setting?. We consider two theoretical case examples:Case 1Jenny2 is a model in her mid-20s who presents to hospital at how to get zestril without prescription the peak of the COVID-19 pandemic with acute appendicitis.

Her surgeon, Miss Schmidt, approaches Jenny to obtain consent for an open appendectomy. Miss Schmidt explains the risks of the operative procedure, and the alternative of conservative management (with intravenous antibiotics) how to get zestril without prescription. Jenny consents to the procedure. However, she develops a postoperative wound infection and an unsightly scar. She does some research and discovers that a laparoscopic procedure would ordinarily have been performed and would have had a lower chance of how to get zestril without prescription wound infection.

She sues Miss Schmidt and the hospital trust where she was treated.Case 2June2s a retired teacher in her early 70s who has well-controlled diabetes and hypertension. She is active and runs a local food bank. Immediately prior to the pandemic lockdown in the UK June had an episode of severe chest pain and how to get zestril without prescription investigations revealed that she has had a non-ST elevation myocardial infarction. The cardiothoracic surgical team recommends that June undergo a PCI although normally her pattern of coronary artery disease would be treated by CABG. When the cardiologist explains that surgery would be normally offered in this situation, and is theoretically superior to PCI, June’s husband how to get zestril without prescription becomes angry and demands that June is listed for surgery.In favour of non-disclosureIt might appear at first glance that doctors should obviously inform Jenny and June about the usual standard of care.

After all, consent cannot be informed if crucial information is lacking. However, one reason that this may be called into question is that it is not immediately clear how it benefits a patient to be informed about alternatives that are not actually available?. In usual circumstances, doctors are not obliged to inform patients about treatments that are performed overseas how to get zestril without prescription but not in the UK. In the UK, for example, there is a rigorous process for assessment of new treatments (not including experimental therapies). Some treatments that are available in other jurisdictions have not been deemed by how to get zestril without prescription the National Institute for Health and Care Excellence (NICE) to be sufficiently beneficial and cost-effective to be offered by the NHS.

It is hard to imagine that a health professional would be found negligent for not discussing with a patient a treatment that NICE has explicitly rejected. The same might apply for novel therapies that are currently unfunded pending formal evaluation by NICE.Of course, the difference is that the treatments we are discussing have been proven (or are believed) to be beneficial and would normally be provided. The Montgomery Ruling of 2015 in the UK established how to get zestril without prescription that patients must be informed of material risks of treatment and reasonable alternatives to treatment. The Bayley –v- George Eliot Hospital NHS Trust5case established that those reasonable alternative treatments must be ‘appropriate treatment’ not just a ‘possible treatment’6. In the current crisis, many previously standard treatments are no longer appropriate given the restrictions how to get zestril without prescription outlined.

In other circumstances they are appropriate. During a pandemic they are no longer appropriate, even if they become appropriate again at some unknown time in the future.In both ethical and legal terms, it is widely accepted that, for consent to be valid, if must be given voluntarily by a person who has capacity to consent and who understands the nature and risks of the treatment. A failure to obtain valid consent, or performing interventions in the absence of consent, could result in criminal proceedings for how to get zestril without prescription assault. Failing to provide adequate information in the consent process could support a claim of negligence. Ethically, adequate information about treatments is essential for the patient to enable them to weigh up options and decide which treatments they wish to undertake.

However, information how to get zestril without prescription about unavailable treatments arguably does not help the patient make an informed decision because it does not give them information that is relevant to consenting or to refusal of treatment that is actually available. If Miss Schmidt had given Jenny information about the relative benefits of laparoscopic appendectomy, that could not have helped Jenny’s decision to proceed with surgery. Her available choices were open appendectomy or how to get zestril without prescription no surgery. Moreover, as the case of June highlights, providing information about alternatives may lead them to desire or even demand those alternative options. This could cause distress both to the patient and the health professional (who is unable to acquiesce).Consideration might also be paid to the effect on patients of disclosure.

How would it how to get zestril without prescription affect a patient with newly diagnosed cancer to tell them that an alternative, perhaps better therapy, might be routinely available in usual circumstances but is not available now?. There is provision in the Montgomery Ruling, in rare circumstances, for therapeutic exception. That is, if information how to get zestril without prescription is significantly detrimental to the health of a patient it might be omitted. We could imagine a version of the case where Jenny was so intensely anxious about the proposed surgery that her surgeon comes to a sincere belief that discussion of the laparoscopic alternative would be extremely distressing or might even lead her to refuse surgery. In most cases, though, it would be hard to be sure that the risks of disclosing alternative (non-available) treatments would be so great that non-disclosure would be justified.In favour of disclosureIn the UK, professional guidance issued by the GMC (General Medical Council) requires doctors to take a personalised approach to information sharing about treatments by sharing ‘with patients the information they want or need in order to make decisions’.

The Montgomery judgement of 20157 broadly endorsed the position of the GMC, requiring patients to be told how to get zestril without prescription about any material risks and reasonable alternatives relevant to the decision at hand. The Supreme Court clarifies that materiality here should be judged by reference to a new two-limbed test founded on the notions of the ‘reasonable person in the patient’s position’ and the ‘particular patient’. One practical test might be for the clinician to ask themselves whether patients in general, or this particular patient might wish to know about alternative forms of treatment that would usually be offered.The GMC has recently produced pandemic-specific guidance8 on consent and decision-making, but this guidance is focused on managing consent in COVID-19-related interventions. While the GMC takes the view that its consent guidelines continue to apply as far as is practical, it also notes that the patient is enabled to consider the ‘reasonable alternatives’, and that the doctor is ‘open and honest with patients about the decision-making process and the criteria for setting priorities in individual cases’.In some situations, there might how to get zestril without prescription be the option of delaying treatment until later. When other surgical procedures are possible.

In that setting, it would be important to ensure that the patient is aware of those future options how to get zestril without prescription (including the risks of delay). For example, if Jenny had symptomatic gallstones, her surgeons might be offering an open cholecystectomy now or the possibility of a laparoscopic surgery at some later point. Understanding the full options open to her now and in the future may have considerable influence on Jenny’s decision. Likewise, if June is aware that she is not being offered standard treatment how to get zestril without prescription she may wish to delay treatment of her atherosclerosis until a later date. Of course, such a delay might lead to greater harm overall.

However, it how to get zestril without prescription would be ethically permissible to delay treatment if that was the patient’s informed choice (just as it would be permissible for the patient to refuse treatment altogether).In the appendicitis case, Jenny does not have the option for delaying her treatment, but the choice for June is more complicated, between immediate PCI which is a second-best treatment versus waiting for standard therapy. Immediate surgery also raises a risk of acquiring nosocomial COVID-19 infection and June is in an age group and has comorbidities that put her at risk of severe COVID-19 disease. Waiting for surgery leaves June at risk of sudden death. For an active and otherwise well patient with coronary disease like June, PCI procedure is not as good a treatment as CABG and June might legitimately wish to take her chances and wait for how to get zestril without prescription the standard treatment. The decision to operate or wait is a balance of risks that only June is fully able to make.

Patients in this scenario will take how to get zestril without prescription different approaches. Patients will need different amounts of information to form their decisions, many patients will need as much information as is available including information about procedures not currently available to make up their mind.June’s husband insists that she should receive the best treatment, and that she should therefore be listed for CABG. Although this treatment would appear to be in June’s best interests, and would respect her autonomy, those ethical considerations are potentially outweighed by distributive justice. The COVID-19 how to get zestril without prescription pandemic of 2020 is being characterised by limitations. Liberties curtailed and choices restricted, this is justified by a need to protect healthcare systems from demand exceeding availability.

While resource allocation is always a relevant ethical concern in publicly funded healthcare systems, it is a dominant concern in a setting where there is a high demand for medical care and scare resources.It is well established that competent adult patients can consent to or refuse medical treatment but they cannot demand that health professionals provide treatments that are contrary to their professional judgement or (even more importantly) would consume scarce healthcare resources. In June’s case, agreeing to perform CABG at a time how to get zestril without prescription when large numbers of patients are critically ill with COVID-19 might mean that another patient is denied access to intensive care (and even dies as a result). Of course, it may be that there are actually available beds in intensive care, and June’s operation would not directly lead to denial of treatment for another patient. However, that does not automatically mean how to get zestril without prescription that surgery must proceed. The hospital may have been justified in making a decision to suspend some forms of cardiac surgery.

That could be on the basis of the need to use the dedicated space, staff and equipment of the cardiothoracic critical care unit for patients with COVID-19. Even if all that physical space is not currently occupied if may not be feasible or practical how to get zestril without prescription to try to simultaneously accommodate some non-COVID-19 patients. (There would be a risk that June would contract COVID-19 postoperatively and end up considerably worse off than she would have been if she had instead received PCI.) Moreover, it seems problematic for individual patients to be able to circumvent policies about allocation of resources purely on the basis that they stand to be disadvantaged by the policy.Perhaps the most significant benefit of disclosure of non-options is transparency and honesty. We suggest that the main reason why Miss Schmidt ought to have how to get zestril without prescription included discussion of the laparoscopic alternative is so that Jenny understands the reasoning behind the decision. If Miss Schmidt had explained to Jenny that in the current circumstances laparoscopic surgery has been stopped, that might have helped her to appreciate that she was being offered the best available management.

It might have enabled a frank discussion about the challenges faced by health professionals in the context of the pandemic and the inevitable need for compromise. It may have avoided awkward discussions how to get zestril without prescription later after Jenny developed her complication.Transparent disclosure should not mean that patients can demand treatment. But it might mean that patients could appeal against a particular policy if they feel that it has been reached unfairly, or applied unfairly. For example, if June became aware that some patients were still being offered CABG, she might (or might not) be justified in appealing against the decision not to offer it to her. Obviously such an appeal would only be how to get zestril without prescription possible if the patient were aware of the alternatives that they were being denied.For patients faced by decisions such as that faced by June, balancing risks of either option is highly personal.

Individuals need to weigh up these decisions for them and require all of the information available to do so. Some information is readily available, for example, the rate of infection for Jenny and the risk of death without how to get zestril without prescription treatment for June. But other risks are unknown, such as the risk of acquiring nosocomial infection with COVID-19. Doctors might feel discomfort talking about unquantifiable risks, but we argue that it is important that the patient has all available information to weigh up options for them, including information that is unknown.ConclusionIn a pandemic, as in other times, doctors should ensure that they offer appropriate medical treatment, based on the needs of an individual. They should aim to provide available treatment that is beneficial and should how to get zestril without prescription not offer treatment that is unavailable or contrary to the patient best interests.

It is ethical. Indeed it is how to get zestril without prescription vital within a public healthcare system, to consider distributive justice in the allocation of treatment. Where treatment is scarce, it may not be possible or appropriate to offer to patients some treatments that would be beneficial and desired by them.Informed consent needs to be individualised. Doctors are obliged to tailor their information to the needs of an individual. We suggest that in the current climate this should include, for most patients, a nuanced open how to get zestril without prescription discussion about alternative treatments that would have been available to them in usual circumstances.

That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing. However, transparency and honesty will usually be the best policy..

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04 September, zestril 20mg tablet 2020 zestril tablet online. Following a comprehensive search, the Board of the Australian Digital Health Agency announced today that Ms Amanda Cattermole PSM will be appointed as Chief Executive Officer of the Agency. Ms Cattermole has a long and distinguished history of senior leadership roles in service delivery in the public sector, leading zestril tablet online high performing organisations, while growing customer satisfaction and staff engagement.

She also has deep expertise in digital transformation across government and within the health sector.Most recently, Ms Cattermole was Chief Operating Officer of Services Australia with responsibility for budget and financial services, people, governance, audit and risk. Ms Cattermole was previously the interim CEO of Services Australia and has held Deputy Secretary roles in health service delivery in the Commonwealth and in the Victorian zestril tablet online State Government. Ms Cattermole holds a Master of Laws from Charles Darwin University, a Master of Business Administration from the University of Western Australia and Bachelor Degrees in Law and Commerce from the University of Melbourne.Welcoming Ms Cattermole’s appointment on behalf of the Agency, Board Chair Dr Elizabeth Deveny said “Amanda Cattermole is held in the highest regard across the public service and health sector and will bring a depth of knowledge and capability to the role of CEO at a time when digital health has never been more important.

The Board has appointed zestril tablet online a leader who is deeply skilled, committed to improving the health of all Australians and who understands the importance of digital innovation in better connecting Australia’s healthcare system.”The Hon Greg Hunt, Minister for Health, said “I am pleased to welcome Ms Cattermole and look forward to working closely together to drive technology in healthcare as the need has never been greater.”The Board of the Agency also acknowledged the invaluable leadership of Ms Bettina McMahon, who has acted as CEO since February this year. €œThe Board of the Agency would like to thank Ms McMahon for her leadership, dedication and commitment, and wishes her the best for the future.”Ms Cattermole will commence on Tuesday 29 September.Media contactAustralian Digital Health Agency Media TeamMobile. 0428 772 421Email.

[email protected] About the Australian Digital Health AgencyThe Agency is tasked with improving health outcomes for all zestril tablet online Australians through the delivery of digital healthcare systems, and implementing Australia’s National Digital Health Strategy – https://www.voiture-et-handicap.fr/buy-zestril-canada/ Safe, Seamless, and Secure. Evolving health and care to meet the needs of modern Australia in collaboration with partners across the community. The Agency is the System Operator of My Health Record, and provides leadership, coordination, and delivery of a collaborative zestril tablet online and innovative approach to utilising technology to support and enhance a clinically safe and connected national health system.

These improvements will give individuals more control of their health and their health information, and support healthcare providers to deliver informed healthcare through access to current clinical and treatment information. Further information zestril tablet online. Www.digitalhealth.gov.auMedia release - Australian Digital Health Agency CEO announced.docx 66KB)Media release - Australian Digital Health Agency CEO announced.pdf (191KB)By operation of the Public Governance, Performance and Accountability (Establishing the Australian Digital Health Agency) Rule 2016, on 1 July 2016, all the assets and liabilities of NEHTA will vest in the Australian Digital Health Agency.

In this website, on and from 1 July 2016, all references to "National E-Health Transition Authority" or "NEHTA" will be deemed zestril tablet online to be references to the Australian Digital Health Agency. PCEHR means the My Health Record, formerly the "Personally Controlled Electronic Health Record", within the meaning of the My Health Records Act 2012 (Cth), formerly called the Personally Controlled Electronic Health Records Act 2012 (Cth). Website Accessibility Copyright ©2015-2020 Australian Digital Health Agency.

04 September, how to get zestril without prescription 2020. Following a comprehensive search, the Board of the Australian Digital Health Agency announced today that Ms Amanda Cattermole PSM will be appointed as Chief Executive Officer of the Agency. Ms Cattermole has how to get zestril without prescription a long and distinguished history of senior leadership roles in service delivery in the public sector, leading high performing organisations, while growing customer satisfaction and staff engagement. She also has deep expertise in digital transformation across government and within the health sector.Most recently, Ms Cattermole was Chief Operating Officer of Services Australia with responsibility for budget and financial services, people, governance, audit and risk.

Ms Cattermole was previously the interim CEO of Services Australia and has held Deputy Secretary roles in health service delivery in the how to get zestril without prescription Commonwealth and in the Victorian State Government. Ms Cattermole holds a Master of Laws from Charles Darwin University, a Master of Business Administration from the University of Western Australia and Bachelor Degrees in Law and Commerce from the University of Melbourne.Welcoming Ms Cattermole’s appointment on behalf of the Agency, Board Chair Dr Elizabeth Deveny said “Amanda Cattermole is held in the highest regard across the public service and health sector and will bring a depth of knowledge and capability to the role of CEO at a time when digital health has never been more important. The Board has appointed a leader who is deeply skilled, committed to improving the health of all Australians and who understands the importance of digital innovation in better connecting Australia’s healthcare system.”The Hon Greg Hunt, Minister for Health, said “I am pleased to welcome Ms Cattermole and look forward to working closely together to drive technology in healthcare as the need has never been greater.”The Board of the Agency also acknowledged the invaluable leadership of Ms Bettina McMahon, who has how to get zestril without prescription acted as CEO since February this year. €œThe Board of the Agency would like to thank Ms McMahon for her leadership, dedication and commitment, and wishes her the best for the future.”Ms Cattermole will commence on Tuesday 29 September.Media contactAustralian Digital Health Agency Media TeamMobile.

0428 772 421Email. [email protected] About the Australian Digital Health AgencyThe Agency is tasked with improving health outcomes for all Australians through the delivery of digital how to get zestril without prescription healthcare systems, and implementing Australia’s National Digital Health Strategy – Safe, Seamless, and Secure. Evolving health and care to meet the needs of modern Australia in collaboration with partners across the community. The Agency is the System Operator of My Health Record, and provides leadership, coordination, and delivery of a how to get zestril without prescription collaborative and innovative approach to utilising technology to support and enhance a clinically safe and connected national health system.

These improvements will give individuals more control of their health and their health information, and support healthcare providers to deliver informed healthcare through access to current clinical and treatment information. Further information how to get zestril without prescription. Www.digitalhealth.gov.auMedia release - Australian Digital Health Agency CEO announced.docx 66KB)Media release - Australian Digital Health Agency CEO announced.pdf (191KB)By operation of the Public Governance, Performance and Accountability (Establishing the Australian Digital Health Agency) Rule 2016, on 1 July 2016, all the assets and liabilities of NEHTA will vest in the Australian Digital Health Agency. In this how to get zestril without prescription website, on and from 1 July 2016, all references to "National E-Health Transition Authority" or "NEHTA" will be deemed to be references to the Australian Digital Health Agency.

PCEHR means the My Health Record, formerly the "Personally Controlled Electronic Health Record", within the meaning of the My Health Records Act 2012 (Cth), formerly called the Personally Controlled Electronic Health Records Act 2012 (Cth). Website Accessibility Copyright ©2015-2020 Australian Digital Health Agency.

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Rheumatic feverIs there https://www.voiture-et-handicap.fr/buy-zestril-canada/ any buy zestril online no prescription disease group more ’deserving’ of a place at the neglected tropical disease table than the post streptococcal illnesses, glomerulonephritis and rheumatic fever?. These dropped off the radar of most high income countries in the second half of the 20th century but have continued to smoulder, largely unchecked, in low and middle income countries (LMICs). The burden buy zestril online no prescription is frightening. 300 000 incident cases per year and 30 million prevalent cases, the damage from chronic carditis resulting, in so many, in heart failure and stroke.There are a number of approaches. Primary prevention (vaccination) remains a work in progress.

Secondary prevention (prompt treatment) is largely dependent on diagnosis which depends buy zestril online no prescription on a positive throat swab or serological evidence in the form of the ASOT and ADB titres and this is where the complexities begin. Tertiary prevention, early diagnosis of heart disease by echo screening and prophylaxis has promise but is gestational. The range of population norms depends on exposure and threshold levels in one country might not be applicable elsewhere inevitably resulting in false positive and buy zestril online no prescription false negative results. Okello et al establishes a range of ASOT levels in urban Uganda and shows much higher mean titres than other comparable populations. Joshua Osowicki and Andrew Steer discuss the implications of these findings in the context of a multipronged approach to rheumatic fever during the wait for the long yearned-for group A streptococcal vaccine.

See pages 825 and buy zestril online no prescription 813Febrile neutropaeniaOncological treatment is prolonged and draining for both a child and their family. A major contributor to the fatigue is the need for recurrent admissions for chemotherapy induced febrile neutropenia (FN). Though evidence of benefit is scanty to non-existent, it is traditional to keep children in hospital on IV antibiotic treatment for several days buy zestril online no prescription irrespective of culture results and clinical appearance. Sereveratne and colleagues assess the safety of a more flexible approach in a tertiary oncology centre, allowing discharge at 48 hours, even if culture positive as long as ‘wellness’ and social criteria were metIn total, 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48 hours microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge.

There were no buy zestril online no prescription deaths from sepsis. This approach won’t work for all episodes of febrile neutropenia, but, probably applies to the majority and the differences to quality of life if adopted widely are hard to overstate. See page 881Infectious disease buy zestril online no prescription mortalityTrends in infectious disease mirror changes in vaccination programmes, society and the environment, diagnostics and microbiological epidemiology. Ferreras-Antolin examines Public Health England data over two eras, 2003 to 2005 and 2013 to 2015. In the latter period, there were 5088 death registrations recorded in children aged 28 days to <15 years in England and Wales (17.6 deaths/100 000 children annually) and, in the first 6897 (23.9/100 000).

The incidence buy zestril online no prescription rate ratio (IRR) of 0.74 (95% CI 0.71 to 0.77) fell significantly and the stories behind these data are revealing. There is little doubt that PCV vaccination has played a role though, in this series, it is too early to assess the contribution of the (2015 launched) meningococcal B programme. The raw data also mask the rise of (the still non-vaccine preventable) invasive group A streptococcal disease (one of the arguments for varicella vaccination) and the future role for Group B streptococcal immunisation. Influenza deaths were rare and, despite a reduction between the eras buy zestril online no prescription was not a major explanator. See page 857Fibre and constipationOne of the more entrenched tenets of child nutrition folklore is that of the association between fibre and constipation.

In a re-analysis of data from the latest NICE review, information from the ALSPAC cohort (in which stool consistency pre-weaning was established) and monozygotic twin studies, Tappin persuasively argues (through triangulation analysis) that fibre is the result of and buy zestril online no prescription confounded by parental response to hard stool and is neither a cause of constipation or a treatment. Laxation (as advocated) should be the first line and used early to prevent the all too familiar chronic issues with undertreatment. Soiling. Loss of self buy zestril online no prescription esteem. Poor mood and loss of appetite.

See page 864Drowning and autismDrowning is a major cause of global buy zestril online no prescription child mortality, particularly in low and middle income country settings. Interventions such as fencing off access and swimming lessons have partially ameliorated the risk, but progress has been slow and awareness probably still the single best form of prophylaxis. Autistic children represent a high risk group due to their inherent communication and behavioural issues. Peden assesses the association between autism and buy zestril online no prescription drowning in Australia from coronial certificates between 2002 and 2018. Of the 667 cases of drowning among 0–19 year olds (with known history), 27 (4%) had an ASD diagnosis, relative risk 2.85 (95% CI 0.61 to 13.24).

Children and adolescents with ASD were significantly more likely to drown when compared with buy zestril online no prescription those without ASD. If aged 5–9 years (44.4% of ASD cases. 13.3% of non ASD cases). In a lake or dam buy zestril online no prescription (25.9% vs 10.0%) and during winter (37.0% vs 13.1%). These sobering figures are likely to be an underestimate as the diagnosis of ASD is often not made until the age of 5 years, past the highest drowning risk preschool group.

Rheumatic feverIs there any disease group more ’deserving’ of a place at the neglected tropical disease table than the post streptococcal https://www.voiture-et-handicap.fr/buy-zestril-canada/ illnesses, how to get zestril without prescription glomerulonephritis and rheumatic fever?. These dropped off the radar of most high income countries in the second half of the 20th century but have continued to smoulder, largely unchecked, in low and middle income countries (LMICs). The burden is frightening how to get zestril without prescription. 300 000 incident cases per year and 30 million prevalent cases, the damage from chronic carditis resulting, in so many, in heart failure and stroke.There are a number of approaches.

Primary prevention (vaccination) remains a work in progress. Secondary prevention (prompt treatment) how to get zestril without prescription is largely dependent on diagnosis which depends on a positive throat swab or serological evidence in the form of the ASOT and ADB titres and this is where the complexities begin. Tertiary prevention, early diagnosis of heart disease by echo screening and prophylaxis has promise but is gestational. The range of how to get zestril without prescription population norms depends on exposure and threshold levels in one country might not be applicable elsewhere inevitably resulting in false positive and false negative results.

Okello et al establishes a range of ASOT levels in urban Uganda and shows much higher mean titres than other comparable populations. Joshua Osowicki and Andrew Steer discuss the implications of these findings in the context of a multipronged approach to rheumatic fever during the wait for the long yearned-for group A streptococcal vaccine. See pages 825 and 813Febrile neutropaeniaOncological treatment is prolonged and draining for both a child and their family how to get zestril without prescription. A major contributor to the fatigue is the need for recurrent admissions for chemotherapy induced febrile neutropenia (FN).

Though evidence of benefit how to get zestril without prescription is scanty to non-existent, it is traditional to keep children in hospital on IV antibiotic treatment for several days irrespective of culture results and clinical appearance. Sereveratne and colleagues assess the safety of a more flexible approach in a tertiary oncology centre, allowing discharge at 48 hours, even if culture positive as long as ‘wellness’ and social criteria were metIn total, 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48 hours microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge. There were how to get zestril without prescription no deaths from sepsis.

This approach won’t work for all episodes of febrile neutropenia, but, probably applies to the majority and the differences to quality of life if adopted widely are hard to overstate. See page 881Infectious disease mortalityTrends in infectious disease mirror changes in vaccination programmes, society and the environment, diagnostics and how to get zestril without prescription microbiological epidemiology. Ferreras-Antolin examines Public Health England data over two eras, 2003 to 2005 and 2013 to 2015. In the latter period, there were 5088 death registrations recorded in children aged 28 days to <15 years in England and Wales (17.6 deaths/100 000 children annually) and, in the first 6897 (23.9/100 000).

The incidence rate ratio (IRR) of 0.74 (95% CI how to get zestril without prescription 0.71 to 0.77) fell significantly and the stories behind these data are revealing. There is little doubt that PCV vaccination has played a role though, in this series, it is too early to assess the contribution of the (2015 launched) meningococcal B programme. The raw data also mask the rise of (the still non-vaccine preventable) invasive group A streptococcal disease (one of the arguments for varicella vaccination) and the future role for Group B streptococcal immunisation. Influenza deaths were how to get zestril without prescription rare and, despite a reduction between the eras was not a major explanator.

See page 857Fibre and constipationOne of the more entrenched tenets of child nutrition folklore is that of the association between fibre and constipation. In a re-analysis of how to get zestril without prescription data from the latest NICE review, information from the ALSPAC cohort (in which stool consistency pre-weaning was established) and monozygotic twin studies, Tappin persuasively argues (through triangulation analysis) that fibre is the result of and confounded by parental response to hard stool and is neither a cause of constipation or a treatment. Laxation (as advocated) should be the first line and used early to prevent the all too familiar chronic issues with undertreatment. Soiling.

Loss of self esteem how to get zestril without prescription. Poor mood and loss of appetite. See page 864Drowning and autismDrowning is a how to get zestril without prescription major cause of global child mortality, particularly in low and middle income country settings. Interventions such as fencing off access and swimming lessons have partially ameliorated the risk, but progress has been slow and awareness probably still the single best form of prophylaxis.

Autistic children represent a high risk group due to their inherent communication and behavioural issues. Peden assesses the association how to get zestril without prescription between autism and drowning in Australia from coronial certificates between 2002 and 2018. Of the 667 cases of drowning among 0–19 year olds (with known history), 27 (4%) had an ASD diagnosis, relative risk 2.85 (95% CI 0.61 to 13.24). Children and adolescents with ASD were significantly more likely how to get zestril without prescription to drown when compared with those without ASD.

If aged 5–9 years (44.4% of ASD cases. 13.3% of non ASD cases). In a lake or dam (25.9% vs 10.0%) and during winter (37.0% vs how to get zestril without prescription 13.1%). These sobering figures are likely to be an underestimate as the diagnosis of ASD is often not made until the age of 5 years, past the highest drowning risk preschool group.

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Under the stewardship of the MidMichigan Health Foundation, this year, 23 area students will received scholarship awards from the Tolfree Scholarship, how can i buy zestril the Dr. George Schaiberger, Sr., Dr how can i buy zestril. Howard VanOosten and Dr. Lloyd Wiegerink Medical Scholarship, and the Paul A how can i buy zestril.

Poling Memorial Scholarship.Awardees receiving the Dr. George Schaiberger, Sr., how can i buy zestril Dr. Howard VanOosten and Dr. Lloyd Wiegerink Medical Staff Memorial Scholarship are how can i buy zestril.

Allie Morand, Camden Groff, Nicholas how can i buy zestril Morse, Anna Erickson, Emily Terry, Brooke Chenette, Tyler Walters, Austin Raymond, Jordan Williams, Andrew Waack, Rylie Alward, Nicholas Thomas and Madison Nachtrieb. Those receiving the Tolfree Scholarship are. Allie Morand, how can i buy zestril Nicholas Morse, Anna Erickson, Emily Terry and Andrew Waack. Lastly, awardees receiving the Paul A.Poling Memorial Scholarship are Emily Terry, Anna Erickson, Nicholas Morse, Allie Morand and Andrew Waack.“The intent of our generous donors in creating these scholarships is to provide our rural counties, particularly those served by MidMichigan Medical Center – West Branch, with future generations of excellent health care professionals,” said Nicole Potter, director, MidMichigan Health Foundation.

€œWe congratulate all of this year’s recipients, as well as the parents and teachers who help them arrive at this major milestone in these students’ how can i buy zestril lives. We wish each one of them the best of success and hope to see them back again in a few years serving the people of their own hometown.”Examples of the health professions being pursued by these individuals include physical therapy, pre-medicine, nursing, health administration, sports medicine, neuroscience and human biology.Applications for the 2021-2022 school year will be accepted from Dec. 1, 2020, through March 1, how can i buy zestril 2021. Those interested in reviewing the eligibility guidelines, including a scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents how can i buy zestril in the Bay area have an additional opportunity to embrace healthy lifestyles near MidMichigan Health Park – Bay.

Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property behind and support from the Foundation, that dream was brought to life.“We are so pleased to be able to support this project how can i buy zestril as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” said Denise O’Keefe, executive director, MidMichigan Health Foundation.Other local organizations came on board to offer help. Tri-County Equipment of Saginaw donated dirt, and the Agriscience classes at John Glenn High School volunteered to get plots prepared for gardening. The Building Trades program at Bay how can i buy zestril Arenac ISD built and installed a tool shed.

Woodchips from Weiler Tree Service were donated to cut down on weeding, and Nature’s Own Landscaping and Irrigation hooked up a spigot in a central location so that all gardeners could access it easily.“During our first season, we had just a few plots of our two-acre garden assigned and less than ten participants,” said Ashleigh Palmer, practice manager, MidMichigan Health Park – Bay. €œThis year, we have all plots filled how can i buy zestril with more than 40 participants. We have couples, families and individuals who share their experience, produce how can i buy zestril and recipes with each other. It’s a lot of fun to see the friendships that have developed among our gardeners.

The ground is fertile, so produce is thriving, and excess vegetables are being donated to patients of the facility.”Jarod Morse, 21, saw how can i buy zestril the garden information on Facebook and is excited to be participating. €œMy whole family - brother, sister and her fiancé, mom, and Papa - are working on the garden together,” Morse stated. A few of the items they are growing are how can i buy zestril cabbage, cauliflower and a variety of peppers. €œThe best part,” he added, “is getting to share knowledge and smiles with other members of the garden.”Rows of produce growing in the community garden, Produce by the Park.MidMichigan Health staffers Shelby Kuch and Kellie Picard do much of the organizing, serving as “garden ambassadors.” They are excited to see it thriving.“It has been fun to see how each person has their own unique approach to gardening and harvesting,” said Kuch.

€œThere are so many things being how can i buy zestril grown. Cabbage, corn, potatoes, broccoli, tomatoes, and beautiful how can i buy zestril sunflowers. You wouldn’t believe the variety and the willingness to share what is harvested with other gardeners, members of the community and patients.”Picard is pleased to see elderly residents becoming involved. €œMany don’t have the how can i buy zestril room to plant where they live,” she explained.

€œThis place gives them a chance to be outside, grow their own food, socialize with others and get some exercise. It’s inspiring to see their work pay off in so many ways.”Those who are interested in securing a plot must fill out an application how can i buy zestril and waiver, and agree to the terms set by Produce by the Park. All skill levels are welcome and there is no cost associated with securing a plot.“Our goal has evolved,” said Palmer. €œWe hope to build upon this year’s successes to increase food security by providing access to fresh, healthy foods while reinforcing ties to the environment and encouraging community members to how can i buy zestril work together.

I think we are well on our way.”Those interested in more information on the Produce by the Park or to request an application may visit www.midmichigan.org/bay/garden or contact Palmer at (989) 778-2888 or ashleigh.palmer@midmichigan.org..

Under the stewardship of the MidMichigan Health Foundation, this year, how to get zestril without prescription 23 area students will received scholarship awards from the Tolfree visite site Scholarship, the Dr. George Schaiberger, how to get zestril without prescription Sr., Dr. Howard VanOosten and Dr. Lloyd Wiegerink Medical Scholarship, how to get zestril without prescription and the Paul A. Poling Memorial Scholarship.Awardees receiving the Dr.

George Schaiberger, Sr., how to get zestril without prescription Dr. Howard VanOosten and Dr. Lloyd Wiegerink Medical how to get zestril without prescription Staff Memorial Scholarship are. Allie Morand, Camden Groff, Nicholas Morse, Anna Erickson, Emily how to get zestril without prescription Terry, Brooke Chenette, Tyler Walters, Austin Raymond, Jordan Williams, Andrew Waack, Rylie Alward, Nicholas Thomas and Madison Nachtrieb. Those receiving the Tolfree Scholarship are.

Allie Morand, Nicholas Morse, Anna how to get zestril without prescription Erickson, Emily Terry and Andrew Waack. Lastly, awardees receiving the Paul A.Poling Memorial Scholarship are Emily Terry, Anna Erickson, Nicholas Morse, Allie Morand and Andrew Waack.“The intent of our generous donors in creating these scholarships is to provide our rural counties, particularly those served by MidMichigan Medical Center – West Branch, with future generations of excellent health care professionals,” said Nicole Potter, director, MidMichigan Health Foundation. €œWe congratulate all of this year’s recipients, as well as the parents and teachers who help them arrive at this how to get zestril without prescription major milestone in these students’ lives. We wish each one of them the best of success and hope to see them back again in a few years serving the people of their own hometown.”Examples of the health professions being pursued by these individuals include physical therapy, pre-medicine, nursing, health administration, sports medicine, neuroscience and human biology.Applications for the 2021-2022 school year will be accepted from Dec. 1, 2020, how to get zestril without prescription through March 1, 2021.

Those interested in reviewing how to get zestril without prescription the eligibility guidelines, including a scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents in the Bay area have an additional opportunity to embrace healthy lifestyles near MidMichigan Health Park – Bay. Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property behind and support from the Foundation, that dream was brought to life.“We are so pleased to be able to support this project as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” said Denise O’Keefe, how to get zestril without prescription executive director, MidMichigan Health Foundation.Other local organizations came on board to offer help. Tri-County Equipment of Saginaw donated dirt, and the Agriscience classes at John Glenn High School volunteered to where to get zestril pills get plots prepared for gardening. The Building Trades program at Bay Arenac ISD built and installed how to get zestril without prescription a tool shed.

Woodchips from Weiler Tree Service were donated to cut down on weeding, and Nature’s Own Landscaping and Irrigation hooked up a spigot in a central location so that all gardeners could access it easily.“During our first season, we had just a few plots of our two-acre garden assigned and less than ten participants,” said Ashleigh Palmer, practice manager, MidMichigan Health Park – Bay. €œThis year, we have all how to get zestril without prescription plots filled with more than 40 participants. We have couples, how to get zestril without prescription families and individuals who share their experience, produce and recipes with each other. It’s a lot of fun to see the friendships that have developed among our gardeners. The ground how to get zestril without prescription is fertile, so produce is thriving, and excess vegetables are being donated to patients of the facility.”Jarod Morse, 21, saw the garden information on Facebook and is excited to be participating.

€œMy whole family - brother, sister and her fiancé, mom, and Papa - are working on the garden together,” Morse stated. A few of the items how to get zestril without prescription they are growing are cabbage, cauliflower and a variety of peppers. €œThe best part,” he added, “is getting to share knowledge and smiles with other members of the garden.”Rows of produce growing in the community garden, Produce by the Park.MidMichigan Health staffers Shelby Kuch and Kellie Picard do much of the organizing, serving as “garden ambassadors.” They are excited to see it thriving.“It has been fun to see how each person has their own unique approach to gardening and harvesting,” said Kuch. €œThere are so many things being grown how to get zestril without prescription. Cabbage, corn, how to get zestril without prescription potatoes, broccoli, tomatoes, and beautiful sunflowers.

You wouldn’t believe the variety and the willingness to share what is harvested with other gardeners, members of the community and patients.”Picard is pleased to see elderly residents becoming involved. €œMany don’t have the room to plant where how to get zestril without prescription they live,” she explained. €œThis place gives them a chance to be outside, grow their own food, socialize with others and get some exercise. It’s inspiring to see how to get zestril without prescription their work pay off in so many ways.”Those who are interested in securing a plot must fill out an application and waiver, and agree to the terms set by Produce by the Park. All skill levels are welcome and there is no cost associated with securing a plot.“Our goal has evolved,” said Palmer.

€œWe hope to build upon this year’s successes to increase food security by providing access to fresh, healthy foods how to get zestril without prescription while reinforcing ties to the environment and encouraging community members to work together. I think we are well on our way.”Those interested in more information on the Produce by the Park or to request an application may visit www.midmichigan.org/bay/garden or contact Palmer at (989) 778-2888 or ashleigh.palmer@midmichigan.org..

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Artificial intelligence technologies are being increasingly relied upon in the healthcare domain, particularly when zestril 20mg it comes to decision support, precision medicine, and the improvement of the quality of care. Regarding primary care specifically, AI also represents an opportunity to assist with electronic health record documentation zestril 20mg. A new study published in the Journal of American Medical Informatics Association this week shows that, although AI documentation assistants (or digital scribes) offer great potential in the primary care setting, they will need to be supervised by a human until strong evidence is available for their autonomous potential.

In workshops with primary care doctors, wrote researchers from the Australian Institute of Health Innovation, "There was consensus zestril 20mg that consultations of the future would increasingly involve more automated and AI-supported systems. However, there were differing views on how this human-AI collaboration would work, what roles doctors and AI would take, and what tasks could be delegated to AI." HIMSS20 Digital Learn on-demand, earn credit, find products and solutions. Get Started zestril 20mg >>.

WHY IT MATTERS Researchers worked with primary care doctors who use EHRs regularly for documentation purposes to understand their views on future AI documentation assistants. They identified three major themes zestril 20mg that emerged from the discussions. Professional autonomy, human-AI collaboration and new models of care.

First, the doctors emphasized the importance of their ability to care for patients in their own way with the abilities AI technology provided."If they [patients] think that we're just getting suggestions from a zestril 20mg computer, then maybe they can just get suggestions from a computer. I think it becomes more difficult to convince them that our recommendations are more valuable than what they can pick up on the internet," said one physician. They noted the need for a bottom-up approach to technology development, with a focus on delivering clear benefits to practice and workflow, and expressed fears around potential legal complications that could stem from working with an AI assistant.With regard to human-AI collaboration, doctors expressed a variety of viewpoints about what tasks could be zestril 20mg delegated to AI.

Many believed that an AI system could assist with tasks such as documentation, referrals and other paperwork. Most said that zestril 20mg AI systems would lack empathy. "GPs voiced several concerns, including some potential biases in patient data and system design, the time needed to fix the errors and train the system, challenges of dealing with complex cases, and the auditing of AI," wrote the researchers.

However, doctors also discussed how AI could help with emerging zestril 20mg models of primary care, including preconsultation, mobile health and telehealth. THE LARGER TREND The question of reducing EHR-related clinician burnout has loomed large, with vendors and researchers trying to pinpoint major causes – and, in turn, potential solutions. AI has been raised as one such solution, with several major EHR vendors offering plans for incorporating zestril 20mg the technology into their workflows.

But human input remains vital, as the new JAMIA study and other research has noted. AI could "bring back meaning and purpose in the practice of medicine while providing new zestril 20mg levels of efficiency and accuracy," wrote Stanford researchers in a 2017 Journal of the American Medical Association study. But, they continued, physicians must "proactively guide, oversee, and monitor the adoption of artificial intelligence as a partner in patient care."ON THE RECORD"AI documentation assistants will likely ...

Be integral to the future zestril 20mg primary care consultations. However, these technologies will still need to be supervised by a human until strong evidence for reliable autonomous performance is available. Therefore, different human-AI collaboration models will need to be designed and zestril 20mg evaluated to ensure patient safety, quality of care, doctor safety, and doctor autonomy," wrote the Australian Institute for Health Innovation researchers.

Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichHealthcare IT News is a HIMSS Media publication.Konica Minolta Healthcare Americas will pay $500,000 to settle a whistleblower zestril 20mg case that alleged its Viztek electronic health record subsidiary had falsified data for certification tests.WHY IT MATTERSIn the qui tam complaint, filed in 2017 in U.S. District Court in New Jersey – where Konica Minolta is based – was filed by whistleblower Leighsa Wilson, who worked for two years at Viztek, best known for its PACS and imaging technologies, as a project manager for its EXA EHR product.In mid-2015, the complaint alleges, Viztek, which was in negotiations to be acquired by Konica Minolta, worked together with InfoGard Laboratories (which was then an ONC-authorized certification and testing body) to make false representations that the EHR software complied with requirements for certification – and qualified for receipt of incentive payments under the federal meaningful use program."To ensure that their product was certified and that their customers received incentive payments, Viztek and Konica Minolta.

(a) falsely attested to InfoGard that their software met zestril 20mg the certification criteria. (b) hard-coded their software to pass certification testing requirements temporarily without ensuring that the software released to customers met certification criteria. And (c) caused their users to falsely attest to using a certified EHR technology, when their software could not support the applicable certification criteria in the field," according to the complaint, which also alleges that InfoGard "facilitated and participated in" these false attestations, "knowingly or with reckless disregard," certifying the EHR software despite its inability to meet ONC's certification criteria.The flaws in Viztek's software "not only rendered the system unreliable and zestril 20mg unable to meet meaningful use standards, but the flaws also created a risk to patient health and safety.

Rather than spend the time and resources necessary to correct the flaws in its EHR software, the EHR defendants opted to do nothing."THE LARGER TRENDThis is only the most recent settlement of this type from health IT vendors accused of False Claims Act violations, of course.Most notable, was the case of eClinicalWorks, which was alleged by the Department of Justice to have falsely claimed meaningful use certification, to have neglected to have safety addressed issues in its software and to have paid kickbacks to clients. That case was settled in 2017 for $155 million.More zestril 20mg recently, similar complaints were lodged against companies such as Practice Fusion and Greenway Health. They settled with DOJ for $145 million and $57 million, respectively."We will be unflagging in our efforts to preserve the accuracy and reliability of Americans’ health records and guard the public against corporate greed," said U.S.

Attorney for the zestril 20mg District of Vermont Christina Nolan after the Greenway case this past year. "EHR companies should consider themselves on notice."ON THE RECORD"The lives of patients depend upon the information processed by electronic health records," said Wilson – who, as a qui tam whistleblower will receive 20% of the financial settlement – in a statement. "Functionality testing and subsequent certification must be performed and obtained through a reliable, measurable process.""Filing a qui tam lawsuit is a powerful and effective way to report problems with EHR software purchased with federal funds and get the problems fixed when they are ignored," said Luke Diamond, an associate at Phillips & zestril 20mg.

Cohen. "The False Claims Act protects whistleblowers from job retaliation and offers rewards if the government recovers funds as a result of the qui tam case.""Our client was concerned about possible patient harm that can occur if EHR software isn't properly certified, so she stepped forward to inform the government about what she had witnessed," said Colette Matzzie, a partner and whistleblower attorney zestril 20mg with Phillips &. Cohen, which brought the case.

"Ensuring that EHR software meets all governmental requirements is important to safeguard both patient care and federal funds."The Arc Madison Cortland zestril 20mg in Oneida, New York, knows that there is a lack of providers that specialize in the intellectual/developmental disability field. Making the problem worse, not so many that understand dual diagnosis.THE PROBLEMWith COVID-19 minimizing the ability for individuals to receive face-to-face services with their providers, many patients are resorting to emergency department visits.Additionally, The Arc is in a rural area requiring travel zestril 20mg to see a provider, and there is a lack of providers in the field. The population itself is underserved, with a lack of transportation to get to appointments.

Without the ability to institute telemedicine as a solution to these problems, the population supported by The Arc zestril 20mg would have seen a lengthy (permanent?. ) pause for needed medical services.PROPOSALThe Arc this year received funding from the FCC to help provide telehealth services.“With this funding we can further treat patients, reduce crisis and allow for social distancing, which is imperative to our vulnerable population,” said Jackie Fahey, director of clinic services at The Arc Madison Cortland. €œWe could provide ongoing services to the individuals we serve to ensure there are no unnecessary emergency department visits zestril 20mg.

This places less of a strain on our local emergency departments and unneeded additional costs.”With the purchase of tablets and headsets and telehealth services from vendor Doxy.me, The Arc was able to still provide medical care to its population of people with an I/DD. Additionally, eliminating emergency department zestril 20mg visits also eliminates their exposure to COVID-19 and eases the burden of the ED providers who are overburdened right now.MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions.

To read this special report, click here.MEETING THE CHALLENGE“When all of our locations were closed abruptly in the middle of March due to the COVID-19 pandemic, we needed to determine a way to quickly and easily implement a telehealth solution so that we were able to still support the individuals that we serve during the crisis, especially when many were under strict quarantine protocols for a variety of reasons,” Fahey explained.“We signed up immediately for the Doxy.me zestril 20mg telehealth platform as it was a user-friendly platform that is HIPAA-compliant. The feature we liked about Doxy.me was that it is web-based, so nothing had to be downloaded and it could easily be used on a laptop, tablet or smartphone.”The Arc rolled out the technology initially with its mental health providers, who offer psychiatry/medication monitoring services, social work counseling and mental health counseling. More than half the organization’s enrollment is enrolled in one or all of these three services, so it was able to continue providing services to a large number of enrolled individuals.“We then began to roll the telehealth services out to nutrition, speech therapy, physical therapy and occupational therapy caseloads if individuals were appropriate to receive the service zestril 20mg through telehealth,” Fahey said.RESULTSThe first success metric The Arc has been able to achieve with the technology is maintaining its utilization for mental health services.

When everything was running normal prior to COVID-19, The Arc’s mental health services made up about 25% of the services it provided on a monthly basis. With the implementation zestril 20mg of telehealth services during the COVID-19 pandemic, the organization was able to achieve 20% of the services provided on a monthly basis.This has shown to staff that they have been able to still serve and respond to the needs of their psychiatry, social work and mental health counseling patients with minimal issues by implementing the telehealth technology.“The second success metric we have been able to achieve with the technology is we have been able to continue to receive referrals for our services and enroll new individuals into the services they need if the services are able to be completed via telehealth,” she said. €œBetween April, May and June, we have enrolled 16 new individuals into ongoing clinic services, which is right on par for our normal enrollment average per month.”USING FCC AWARD FUNDSThe Arc Madison Cortland was awarded $49,455 by the FCC earlier this year for laptop computers and headsets to provide remote consultations and treatment during the COVID-19 pandemic for psychological services, counseling, and occupational and physical therapy for people with developmental and other disabilities.“With the funds, we purchased headsets and tablets to allow the people we support to have access to medical appointments, along with physical therapy, occupational therapy and psychology appointments remotely,” Fahey explained.

€œThe technology enables us to continue to provide these services at a time when the people we support are unable to leave for traditional in-person appointments.“Because these are such uncertain times, and a time frame for when we may return to ‘normalcy’ is unknown, the zestril 20mg technology allows us to continue delivering medical support without the concern of a pause in those services.”Twitter. @SiwickiHealthITEmail the writer. Bill.siwicki@himss.orgHealthcare IT News is a HIMSS Media publication.HIMSSCast host Jonah Comstock convenes a panel of HIMSS Media editors – HITN Senior Editor Kat Jercich, MobiHealthNews Associate Editor Dave Muoio and HFN Associate Editor Jeff Lagasse – to discuss recent delivery slowdowns at the Post Office and how they have and haven't affected healthcare stakeholders, zestril 20mg including startups and patients.

The team also looks into the broader trend of the politicization of traditionally apolitical government agencies and how that could affect public faith in COVID-19 treatments or vaccines.More about this episode:USPS service delays are hitting some mail-order pharmacies and telehealth platforms harder than othersMail delays may affect medication supply for nearly 1 in 4 Americans over 50Postmaster General Louis DeJoy's full testimony (C-SPAN)The Package Coalition homepageThe Trump administration this week asked the U.S. Supreme Court to reverse a lower zestril 20mg court ruling that allowed for mail-order and telemedicine abortion during the COVID-19 crisis. U.S.

Food and Drug Administration regulations require mifepristone, which is used in medication abortion, to be dispensed at a clinic, hospital or medical zestril 20mg office. In June, U.S. District Judge for the District of Maryland Theodore Chuang blocked the requirements during the pandemic, finding zestril 20mg them to be a "substantial obstacle." Mifepristone, in combination with misoprostol, is FDA-approved for abortions up to ten weeks' gestation.

In 2017, a New England Journal of Medicine article argued against the FDA regulations for mifepristone given the drug's safety record. WHY IT MATTERS Acting Solicitor General zestril 20mg Jeffrey B. Wall applied for a stay of Chuang's injunction on Wednesday as the case makes its way through the lower courts, arguing that the regulations do not represent an undue burden.

"The safety requirements here concern only medication abortions using Mifeprex, which is approved for use only during zestril 20mg the first ten weeks of pregnancy. They have no effect on the availability of surgical abortions, a method that this Court has treated as safe for women," wrote Wall. Reproductive rights groups spoke out against the move, noting that people of color are disproportionately affected both by abortion restrictions and by the COVID-19 zestril 20mg pandemic.

"Black, Brown, Indigenous people and people of color are already dying/getting sick at disproportionate rates from COVID-19," said All Above All* on Twitter. "The Trump-Pence admin is trying to make this worse by asking SCOTUS to require people face unnecessary risk just to get abortion care." "The FDA’s in-person requirements on mifepristone zestril 20mg subject patients to unnecessary exposure to a deadly virus, and two federal courts have already rejected the Trump administration’s argument. Forcing patients to travel to a health center to access the safe, effective medication they need especially hurts people of color and people with low-incomes, who already face more barriers to care," said Planned Parenthood Federation of America President and CEO Alexis McGill-Johnson in a statement.THE LARGER TREND The COVID-19 pandemic has exacerbated many existing barriers to care, including for reproductive health services.

"We’ve seen the undue burden and hardship these zestril 20mg restrictions create during COVID-19, especially in communities hit hardest by the pandemic," said Skye Perryman, chief legal officer at the American College of Obstetricians and Gynecologists, a co-plaintiff in the telemedicine case, to Healthcare IT News. In response to the July ruling, some abortion providers reportedly moved to delivering mifepristone by mail. Still, others faced state laws that restricted zestril 20mg the provision of abortion via telemedicine.And as Dr.

Jacquelyn Yeh from Physicians from Reproductive Health pointed out in July, telemedicine itself involves hurdles such as broadband access and privacy concerns. It remains to be seen whether the Supreme Court will grant the zestril 20mg Trump administration's request. ON THE RECORD "As COVID-19 ravages Black, Latino, Indigenous, and other communities of color across the country, the Trump administration should be aiming to keep us healthy – not moving forward with an agenda to endanger people who seek abortion," said McGill-Johnson.

Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichHealthcare IT News is a HIMSS Media publication..

Artificial intelligence technologies are being increasingly relied upon in the healthcare domain, particularly when it comes to decision support, precision medicine, how to get zestril without prescription and the improvement of the quality of care. Regarding primary care specifically, AI also represents an opportunity to assist with how to get zestril without prescription electronic health record documentation. A new study published in the Journal of American Medical Informatics Association this week shows that, although AI documentation assistants (or digital scribes) offer great potential in the primary care setting, they will need to be supervised by a human until strong evidence is available for their autonomous potential. In workshops with primary care doctors, wrote researchers from the Australian Institute of Health Innovation, "There was consensus that consultations of the future would increasingly how to get zestril without prescription involve more automated and AI-supported systems. However, there were differing views on how this human-AI collaboration would work, what roles doctors and AI would take, and what tasks could be delegated to AI." HIMSS20 Digital Learn on-demand, earn credit, find products and solutions.

Get Started >> how to get zestril without prescription. WHY IT MATTERS Researchers worked with primary care doctors who use EHRs regularly for documentation purposes to understand their views on future AI documentation assistants. They identified three major themes how to get zestril without prescription that emerged from the discussions. Professional autonomy, human-AI collaboration and new models of care. First, the doctors emphasized the importance of their ability how to get zestril without prescription to care for patients in their own way with the abilities AI technology provided."If they [patients] think that we're just getting suggestions from a computer, then maybe they can just get suggestions from a computer.

I think it becomes more difficult to convince them that our recommendations are more valuable than what they can pick up on the internet," said one physician. They noted the need for a bottom-up approach to technology development, with a focus on delivering clear benefits to practice and workflow, and expressed fears around potential legal complications that could stem from working with an AI assistant.With regard to how to get zestril without prescription human-AI collaboration, doctors expressed a variety of viewpoints about what tasks could be delegated to AI. Many believed that an AI system could assist with tasks such as documentation, referrals and other paperwork. Most said that AI how to get zestril without prescription systems would lack empathy. "GPs voiced several concerns, including some potential biases in patient data and system design, the time needed to fix the errors and train the system, challenges of dealing with complex cases, and the auditing of AI," wrote the researchers.

However, doctors also discussed how AI how to get zestril without prescription could help with emerging models of primary care, including preconsultation, mobile health and telehealth. THE LARGER TREND The question of reducing EHR-related clinician burnout has loomed large, with vendors and researchers trying to pinpoint major causes – and, in turn, potential solutions. AI has been raised as one such solution, with several major EHR how to get zestril without prescription vendors offering plans for incorporating the technology into their workflows. But human input remains vital, as the new JAMIA study and other research has noted. AI could "bring back meaning and purpose in the practice of medicine while providing new how to get zestril without prescription levels of efficiency and accuracy," wrote Stanford researchers in a 2017 Journal of the American Medical Association study.

But, they continued, physicians must "proactively guide, oversee, and monitor the adoption of artificial intelligence as a partner in patient care."ON THE RECORD"AI documentation assistants will likely ... Be integral to how to get zestril without prescription the future primary care consultations. However, these technologies will still need to be supervised by a human until strong evidence for reliable autonomous performance is available. Therefore, different human-AI collaboration models will need to be designed and evaluated to ensure patient safety, quality of care, doctor safety, and doctor how to get zestril without prescription autonomy," wrote the Australian Institute for Health Innovation researchers. Kat Jercich is senior editor of Healthcare IT News.Twitter.

@kjercichHealthcare IT News is a HIMSS Media publication.Konica Minolta Healthcare Americas will pay $500,000 to settle a whistleblower case that alleged its Viztek electronic health record subsidiary had falsified data for certification tests.WHY IT MATTERSIn the qui tam complaint, filed in how to get zestril without prescription 2017 in U.S. District Court in New Jersey – where Konica Minolta is based – was filed by whistleblower Leighsa Wilson, who worked for two years at Viztek, best known for its PACS and imaging technologies, as a project manager for its EXA EHR product.In mid-2015, the complaint alleges, Viztek, which was in negotiations to be acquired by Konica Minolta, worked together with InfoGard Laboratories (which was then an ONC-authorized certification and testing body) to make false representations that the EHR software complied with requirements for certification – and qualified for receipt of incentive payments under the federal meaningful use program."To ensure that their product was certified and that their customers received incentive payments, Viztek and Konica Minolta. (a) falsely attested to InfoGard how to get zestril without prescription that their software met the certification criteria. (b) hard-coded their software to pass certification testing requirements temporarily without ensuring that the software released to customers met certification criteria. And (c) caused their users to falsely attest to using a certified EHR technology, when their software could not support the applicable certification criteria in the field," according to the complaint, which also alleges that InfoGard "facilitated and participated in" these false attestations, "knowingly or with reckless disregard," certifying the EHR software despite its inability to meet ONC's certification criteria.The flaws in Viztek's how to get zestril without prescription software "not only rendered the system unreliable and unable to meet meaningful use standards, but the flaws also created a risk to patient health and safety.

Rather than spend the time and resources necessary to correct the flaws in its EHR software, the EHR defendants opted to do nothing."THE LARGER TRENDThis is only the most recent settlement of this type from health IT vendors accused of False Claims Act violations, of course.Most notable, was the case of eClinicalWorks, which was alleged by the Department of Justice to have falsely claimed meaningful use certification, to have neglected to have safety addressed issues in its software and to have paid kickbacks to clients. That case how to get zestril without prescription was settled in 2017 for $155 million.More recently, similar complaints were lodged against companies such as Practice Fusion and Greenway Health. They settled with DOJ for $145 million and $57 million, respectively."We will be unflagging in our efforts to preserve the accuracy and reliability of Americans’ health records and guard the public against corporate greed," said U.S. Attorney for the District of how to get zestril without prescription Vermont Christina Nolan after the Greenway case this past year. "EHR companies should consider themselves on notice."ON THE RECORD"The lives of patients depend upon the information processed by electronic health records," said Wilson – who, as a qui tam whistleblower will receive 20% of the financial settlement – in a statement.

"Functionality testing and subsequent certification must be performed and obtained through a reliable, measurable process.""Filing a qui tam lawsuit is a powerful and effective how to get zestril without prescription way to report problems with EHR software purchased with federal funds and get the problems fixed when they are ignored," said Luke Diamond, an associate at Phillips &. Cohen. "The False Claims Act protects whistleblowers from job retaliation and offers rewards if the government recovers funds as a result of the qui tam case.""Our client was concerned about possible patient harm that can occur if EHR software isn't properly certified, so she stepped forward to inform the government about what she had witnessed," how to get zestril without prescription said Colette Matzzie, a partner and whistleblower attorney with Phillips &. Cohen, which brought the case. "Ensuring that EHR software meets all governmental how to get zestril without prescription requirements is important to safeguard both patient care and federal funds."The Arc Madison Cortland in Oneida, New York, knows that there is a lack of providers that specialize in the intellectual/developmental disability field.

Making the problem worse, not so many that understand dual diagnosis.THE PROBLEMWith COVID-19 minimizing the ability for individuals to receive face-to-face services with their providers, many how to get zestril without prescription patients are resorting to emergency department visits.Additionally, The Arc is in a rural area requiring travel to see a provider, and there is a lack of providers in the field. The population itself is underserved, with a lack of transportation to get to appointments. Without the ability to institute telemedicine as a solution to these problems, the population how to get zestril without prescription supported by The Arc would have seen a lengthy (permanent?. ) pause for needed medical services.PROPOSALThe Arc this year received funding from the FCC to help provide telehealth services.“With this funding we can further treat patients, reduce crisis and allow for social distancing, which is imperative to our vulnerable population,” said Jackie Fahey, director of clinic services at The Arc Madison Cortland. €œWe could provide ongoing services to the individuals we how to get zestril without prescription serve to ensure there are no unnecessary emergency department visits.

This places less of a strain on our local emergency departments and unneeded additional costs.”With the purchase of tablets and headsets and telehealth services from vendor Doxy.me, The Arc was able to still provide medical care to its population of people with an I/DD. Additionally, eliminating emergency department visits also eliminates their exposure to how to get zestril without prescription COVID-19 and eases the burden of the ED providers who are overburdened right now.MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions. To read this special report, click how to get zestril without prescription here.MEETING THE CHALLENGE“When all of our locations were closed abruptly in the middle of March due to the COVID-19 pandemic, we needed to determine a way to quickly and easily implement a telehealth solution so that we were able to still support the individuals that we serve during the crisis, especially when many were under strict quarantine protocols for a variety of reasons,” Fahey explained.“We signed up immediately for the Doxy.me telehealth platform as it was a user-friendly platform that is HIPAA-compliant. The feature we liked about Doxy.me was that it is web-based, so nothing had to be downloaded and it could easily be used on a laptop, tablet or smartphone.”The Arc rolled out the technology initially with its mental health providers, who offer psychiatry/medication monitoring services, social work counseling and mental health counseling.

More than half the organization’s enrollment is enrolled in one or all of these three services, so it was able to continue providing services to a large number of enrolled individuals.“We then began to roll the telehealth services out to nutrition, speech therapy, physical therapy and occupational therapy caseloads if individuals were appropriate to receive how to get zestril without prescription the service through telehealth,” Fahey said.RESULTSThe first success metric The Arc has been able to achieve with the technology is maintaining its utilization for mental health services. When everything was running normal prior to COVID-19, The Arc’s mental health services made up about 25% of the services it provided on a monthly basis. With the implementation of telehealth services during the COVID-19 pandemic, the organization was able to achieve 20% of the services provided on a monthly basis.This has shown to staff that they have been able to still serve and respond to the needs of their psychiatry, social work and mental health counseling patients with minimal issues by implementing the telehealth technology.“The second success metric we have been able to how to get zestril without prescription achieve with the technology is we have been able to continue to receive referrals for our services and enroll new individuals into the services they need if the services are able to be completed via telehealth,” she said. €œBetween April, May and June, we have enrolled 16 new individuals into ongoing clinic services, which is right on par for our normal enrollment average per month.”USING FCC AWARD FUNDSThe Arc Madison Cortland was awarded $49,455 by the FCC earlier this year for laptop computers and headsets to provide remote consultations and treatment during the COVID-19 pandemic for psychological services, counseling, and occupational and physical therapy for people with developmental and other disabilities.“With the funds, we purchased headsets and tablets to allow the people we support to have access to medical appointments, along with physical therapy, occupational therapy and psychology appointments remotely,” Fahey explained. €œThe technology enables us to continue to provide these services at a time when the people we support are unable to leave for traditional in-person appointments.“Because these are such uncertain times, and a time frame for when we may return to ‘normalcy’ is unknown, the technology allows how to get zestril without prescription us to continue delivering medical support without the concern of a pause in those services.”Twitter.

@SiwickiHealthITEmail the writer. Bill.siwicki@himss.orgHealthcare IT News is a HIMSS Media publication.HIMSSCast host Jonah Comstock convenes a panel of HIMSS Media editors – HITN Senior Editor how to get zestril without prescription Kat Jercich, MobiHealthNews Associate Editor Dave Muoio and HFN Associate Editor Jeff Lagasse – to discuss recent delivery slowdowns at the Post Office and how they have and haven't affected healthcare stakeholders, including startups and patients. The team also looks into the broader trend of the politicization of traditionally apolitical government agencies and how that could affect public faith in COVID-19 treatments or vaccines.More about this episode:USPS service delays are hitting some mail-order pharmacies and telehealth platforms harder than othersMail delays may affect medication supply for nearly 1 in 4 Americans over 50Postmaster General Louis DeJoy's full testimony (C-SPAN)The Package Coalition homepageThe Trump administration this week asked the U.S. Supreme Court how to get zestril without prescription to reverse a lower court ruling that allowed for mail-order and telemedicine abortion during the COVID-19 crisis. U.S.

Food and Drug Administration regulations how to get zestril without prescription require mifepristone, which is used in medication abortion, to be dispensed at a clinic, hospital or medical office. In June, U.S. District Judge for the District of Maryland Theodore Chuang blocked the requirements during the pandemic, finding them to be a "substantial obstacle." Mifepristone, in combination with misoprostol, is FDA-approved for abortions how to get zestril without prescription up to ten weeks' gestation. In 2017, a New England Journal of Medicine article argued against the FDA regulations for mifepristone given the drug's safety record. WHY IT MATTERS how to get zestril without prescription Acting Solicitor General Jeffrey B.

Wall applied for a stay of Chuang's injunction on Wednesday as the case makes its way through the lower courts, arguing that the regulations do not represent an undue burden. "The safety requirements here concern only medication abortions using Mifeprex, which is approved for use only during how to get zestril without prescription the first ten weeks of pregnancy. They have no effect on the availability of surgical abortions, a method that this Court has treated as safe for women," wrote Wall. Reproductive rights groups spoke out against the move, noting that people of color how to get zestril without prescription are disproportionately affected both by abortion restrictions and by the COVID-19 pandemic. "Black, Brown, Indigenous people and people of color are already dying/getting sick at disproportionate rates from COVID-19," said All Above All* on Twitter.

"The Trump-Pence admin is trying to make this worse by asking SCOTUS to require people face how to get zestril without prescription unnecessary risk just to get abortion care." "The FDA’s in-person requirements on mifepristone subject patients to unnecessary exposure to a deadly virus, and two federal courts have already rejected the Trump administration’s argument. Forcing patients to travel to a health center to access the safe, effective medication they need especially hurts people of color and people with low-incomes, who already face more barriers to care," said Planned Parenthood Federation of America President and CEO Alexis McGill-Johnson in a statement.THE LARGER TREND The COVID-19 pandemic has exacerbated many existing barriers to care, including for reproductive health services. "We’ve seen the undue burden and hardship how to get zestril without prescription these restrictions create during COVID-19, especially in communities hit hardest by the pandemic," said Skye Perryman, chief legal officer at the American College of Obstetricians and Gynecologists, a co-plaintiff in the telemedicine case, to Healthcare IT News. In response to the July ruling, some abortion providers reportedly moved to delivering mifepristone by mail. Still, others faced state laws that restricted the provision of abortion how to get zestril without prescription via telemedicine.And as Dr.

Jacquelyn Yeh from Physicians from Reproductive Health pointed out in July, telemedicine itself involves hurdles such as broadband access and privacy concerns. It how to get zestril without prescription remains to be seen whether the Supreme Court will grant the Trump administration's request. ON THE RECORD "As COVID-19 ravages Black, Latino, Indigenous, and other communities of color across the country, the Trump administration should be aiming to keep us healthy – not moving forward with an agenda to endanger people who seek abortion," said McGill-Johnson. Kat Jercich is senior editor how to get zestril without prescription of Healthcare IT News.Twitter. @kjercichHealthcare IT News is a HIMSS Media publication..

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