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Have you ever woken up with a sore throat and buy lasix with free samples used your phone to get a virtual visit?. The odds are it’s not available to you, and there is a reason for that. You may be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during COVID-19 and how health systems are offering virtual access like never before.

There’s a reason buy lasix with free samples for that, too. For the past few weeks I’ve seen Facebook posts daily from former nursing colleagues in metro Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with COVID-19. It makes me very proud to call these nurses my friends.

As a former emergency department nurse, I recall the feeling buy lasix with free samples of satisfaction knowing that I’ve helped someone on the worst day of their life. One of the best parts of being a nurse is knowing you matter to the only person in health care that truly matters. The patient.

Several years ago I made the difficult decision buy lasix with free samples to no longer perform bedside nursing and become a nurse administrator. The biggest loss from my transition is the feeling that what I do matters to the patient. COVID-19 has forced a lot of us to rethink the role we play in health care and what the real priority should be.

Things that were top priorities three buy lasix with free samples months ago have been rightfully cast aside to either care for patients in a pandemic or prepare for the unknown future of, “When is our turn?. € For me, COVID-19 has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront of care during this crisis. It has also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently.

When I became the director of virtual care at our organization in 2015 I knew nothing about buy lasix with free samples telehealth. Sure, I had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company lets them FaceTime a doctor for free (spoiler alert. It’s not FaceTime).

I was tech-savvy from a consumer perspective and a tech novice buy lasix with free samples from an IT perspective. Nevertheless, my team and I spent the next few years learning as we built one of the higher volume virtual care networks in the state of Michigan. We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around those barriers.

But, there were two obstacles that we could not overcome buy lasix with free samples. Government regulation and insurance provider willingness to cover virtual visits. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home.

The need to social buy lasix with free samples distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place created instant demand for direct-to-consumer virtual care. In all honesty, I’ve always considered direct-to-consumer virtual care to be the flashy, must-have holiday gift of the year that organizations are convinced will be the way of the future. If a health system wants to provide on-demand access to patients for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health system’s logo on it.

What a health system will struggle with buy lasix with free samples is to find is enough patient demand to cover the high cost. Remember my friends from earlier that told me about the app their insurance gave them?. Nearly all of them followed that up by telling me they’ve never actually used it.

I am fortunate that I work for an organization that understands this buy lasix with free samples and instead focuses on how can we provide care that our patients actually want and need from the doctors they want to see. Ironically, this fiscal year we had a corporate top priority around direct-to-consumer virtual care. We wanted to expand what we thought were some successful pilots and perform 500 direct-to-consumer visits.

This year has been one of the buy lasix with free samples hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority. With only four months left, we were only about halfway there. The biggest problem we ran into was that every great idea a physician brought to me was instantly dead in the water because practically no insurance company would pay for it.

There are (prior to COVID-19) a plethora buy lasix with free samples of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a health care facility. It is extremely limited what will be paid for in the patient home and most of it is so specific that the average patient isn’t eligible to get any in-home virtual care. Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would be covered if it happened in office.

Add to that the massive capital and operating expenses it takes to build a virtual care network and you can buy lasix with free samples see why these programs don’t exist. A month ago I was skeptical we’d have a robust direct-to-consumer program any time soon and then COVID-19 hit. When COVID-19 started to spread rapidly in the United States, regulations and reimbursement rules were being stripped daily.

The first change that had major impact is when the Centers for Medicare and Medicaid Services (CMS) announced that they would temporarily buy lasix with free samples begin reimbursing for virtual visits conducted in the patient’s home for COVID-19 and non-COVID related visits. We were already frantically designing a virtual program to handle the wave of COVID-19 screening visits that were overloading our emergency departments and urgent cares. We were having plenty of discussions around reimbursement for this clinic.

Do we attempt to bill insurances knowing they buy lasix with free samples will likely deny, do we do a cash clinic model or do we do this as a community benefit and eat the cost?. The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing. Realistically we don’t know if we will be paid for any of this.

We are holding all buy lasix with free samples of the bills for at least 90 days while the industry sorts out the rules. I was excited by the reimbursement announcement because I knew we had eliminated one of the biggest direct-to-consumer virtual care barriers. However, I was quickly brought back to reality when I was reminded that HIPAA (Health Insurance Portability and Accountability Act) still existed.

I had this crazy idea that during buy lasix with free samples a pandemic we should make it as easy as possible for people to receive virtual care and that the best way to do that was to meet the patient on the device they are most comfortable with and the application (FaceTime, Facebook, Skype, etc.) that they use every day. The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because “it’s not secure.” I’m not quite sure what a hacker stands to gain by listening into to my doctor and me talk about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry. Sure, not every health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a “non-secure” app but why not let the patient decide through informed consent?.

Regulators could also abandon this all-or-nothing approach and lighten regulations buy lasix with free samples surrounding specific health conditions. The idea that regulations change based on medical situation is not new. For example, in my home state of Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance abuse.

Never mind that this same information is freely buy lasix with free samples given over the phone by every office around the country daily without issue, but I digress. While my job is to innovate new pathways for care, our lawyer’s job is to protect the organization and he, along with IT security, rightfully shot down my consumer applications idea. A few days later I legitimately screamed out loud in joy when the Department of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications.

The elimination of billing restrictions and HIPAA regulations changed buy lasix with free samples what is possible for health care organizations to offer virtually. Unfortunately both changes are listed as temporary and will likely be removed when the pandemic ends. Six days after the HIPAA changes were announced, we launched a centralized virtual clinic for any patient that wanted a direct-to-consumer video visit to be screened by a provider for COVID-19.

It allows patients buy lasix with free samples to call in without a referral and most patients are on-screen within five minutes of clicking the link we text them. They don’t have to download an app, create an account or even be an established patient of our health system. It saw over 900 patients in the first 12 days it was open.

That is 900 real patients that received care from a physician or advanced practice provider without risking personal exposure and without going to an already overwhelmed buy lasix with free samples ED or urgent care. To date, 70 percent of the patients seen by the virtual clinic did not meet CDC testing criteria for COVID-19. I don’t believe we could have reached even half of these patients had the consumer application restrictions been kept.

A program like this almost certainly wouldn’t exist if not for the regulations being lifted and even if it did, it would have taken six to buy lasix with free samples 12 months to navigate barriers and implement in normal times. Sure, the urgency of a pandemic helps but the impact of provider, patients, regulators and payors being on the same page is what fueled this fire. During the virtual clinic’s first two weeks, my team turned its attention to getting over 300 providers across 60+ offices virtual so they could see their patients at home.

Imagine being an immunocompromised cancer patient right now and being asked to leave your home and be exposed to other people in order to see your buy lasix with free samples oncologist. Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldn’t be covered by insurance even if you did navigate the clunky apps that are HIPAA compliant. Do we really think the immunocompromised cancer patient feels any more comfortable every normal flu season?.

Is it any more appropriate to ask them to risk exposure to the buy lasix with free samples flu than it is to COVID-19?. And yet we deny them this access in normal times and it quite possibly will be stripped away from them when this crisis is over. Now 300 to 400 patients per day in our health system are seen virtually by their own primary care doctor or specialist for non-COVID related visits.

Not a single one of these would have been reimbursed one month ago and buy lasix with free samples I am highly skeptical I would have gotten approval to use the software that connects us to the patient. Lastly, recall that prior to COVID-19, our system had only found 250 total patients that direct-to-consumer care was value-added and wasn’t restricted by regulation or reimbursement. COVID-19 has been a wake-up call to the whole country and health care is no exception.

It has put priorities in perspective and shined a light on what is truly buy lasix with free samples value-added. For direct-to-consumer virtual care it has shown us what is possible when we get out of our own way. If a regulation has to be removed to allow for care during a crisis then we must question why it exists in the first place.

HIPAA regulation cannot go back to its antiquated practices buy lasix with free samples if we are truly going to shift the focus to patient wellness. CMS and private payors must embrace value-added direct-to-consumer virtual care and allow patients the access they deserve. COVID-19 has forced this industry forward, we cannot allow it to regress and be forgotten when this is over.

Tom Wood is the director of trauma and virtual care for MidMichigan Health, a buy lasix with free samples non-profit health system headquartered in Midland, Michigan, affiliated with Michigan Medicine, the health care division of the University of Michigan. The views and opinions expressed in this commentary are his own.When dealing with all of the aspects of diabetes, it’s easy to let your feel fall to the bottom of the list. But daily care and evaluation is one of the best ways to prevent foot complications.

It’s important to identify your risk factors and take the proper steps in buy lasix with free samples limiting your complications. Two of the biggest complications with diabetes are peripheral neuropathy and ulcer/amputation. Symptoms of peripheral neuropathy include numbness, tingling and/or burning in your feet and legs.

You can slow the progression of developing neuropathy by making it a point to buy lasix with free samples manage your blood sugars and keep them in the normal range. If you are experiencing these symptoms, it is important to establish and maintain a relationship with a podiatrist. Your podiatrist can make sure things are looking healthy and bring things to your attention to monitor and keep a close eye on.

Open wounds or ulcers can develop secondary to buy lasix with free samples trauma, pressure, diabetes, neuropathy or poor circulation. If ulcerations do develop, it’s extremely important to identify the cause and address it. Ulcers can get worse quickly, so it’s necessary to seek immediate medical treatment if you find yourself or a loved one dealing with this complication.

Untreated ulcerations often lead to amputation and can be avoided if proper medical attention is buy lasix with free samples sought right away. There are important things to remember when dealing with diabetic foot care. It’s very important to inspect your feet daily, especially if you have peripheral neuropathy.

You may have a cut or a sore on your feet that you can’t feel, so your body doesn’t alarm you to check your feet. Be gentle when bathing your feet. Moisturize your feet, but not between your toes.

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How to cite canadian pharmacy lasix this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J canadian pharmacy lasix Psychiatry 2020;62:457-8COVID-19 pandemic is expected to bring a Tsunami of mental health issues. Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided.

Viral infections are known to be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia canadian pharmacy lasix. There was an increased incidence of psychiatric disorders following the Influenza Pandemic. Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized as dementia praecox, delirium, other canadian pharmacy lasix psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus.

Loss of smell and taste as an initial symptom points toward early canadian pharmacy lasix involvement of olfactory bulb. The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may be either due to the direct canadian pharmacy lasix effect of the virus on the brain or due to the neuropsychiatric effects of drugs used to treat the infection or its complications.

For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, North CS canadian pharmacy lasix. Mental health and the COVID-19 pandemic. N Engl J Med canadian pharmacy lasix 2020;383:510-2.

2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, China canadian pharmacy lasix. The mystery and the miracle. J Med Virol 2020;92:401-2.

3.Fodoulian L, Tuberosa J, canadian pharmacy lasix Rossier D, Landis BN, Carleton A, Rodriguez I. SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 canadian pharmacy lasix. Doi.

Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system. Adv Drug Deliv Rev 2012;64:614-28.

5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections. A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27.

6.Steardo L Jr., Steardo L, Verkhratsky A. Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health. Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers.

The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences. Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords.

Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS. Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle. The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability.

No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience. The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.).

The dialog occurs in the 6th chapter of the epic and has over 700 verses. In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era. Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2).

The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems. The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus.

A glaring example is the use of face masks, known to effectively slow the viral infection. Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!. Path of Action The second key concept is the path of action (Karma yoga, chapter 3).

Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin. Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself.

Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not. Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties. Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6).

It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%. Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines.

Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications. These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C. Lessons learned from the coronavirus health crisis in Madrid, Spain.

How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1. [doi. 10.1016/j.biopsych.

2020.04.003]. 3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

Oxford, England. Oxford University Press. In Press. 4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al.

Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87. Doi. 10.1038/s41562-020-0906-x.

Epub 2020 Jun 24. 5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22]. J Altern Complement Med 2020;26:10.1089/acm.

7.Gupta H, Gupta M, Bhargava S. Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25]. Gerontology 2020:26;1-8.

[doi. 10.1159/000509216]. 9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29].

Eur J Pharmacol 2020;882:173329. 10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2. 12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V.

The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21. 13.Keshavan MS. Pandemics and psychiatry.

Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7]. Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness. Schizophr Res 2020;218:36-7.

Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

How to cite this article:Singh buy lasix with free samples OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 buy lasix with free samples pandemic is expected to bring a Tsunami of mental health issues.

Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided. Viral infections are known to be buy lasix with free samples associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza Pandemic.

Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized as dementia praecox, delirium, buy lasix with free samples other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus. Loss of smell and taste as an initial symptom points toward buy lasix with free samples early involvement of olfactory bulb.

The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may be either due to the direct effect of the virus on the brain or due to buy lasix with free samples the neuropsychiatric effects of drugs used to treat the infection or its complications.

For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, buy lasix with free samples North CS. Mental health and the COVID-19 pandemic.

N Engl buy lasix with free samples J Med 2020;383:510-2. 2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, buy lasix with free samples China.

The mystery and the miracle. J Med Virol 2020;92:401-2. 3.Fodoulian L, Tuberosa J, Rossier D, Landis BN, Carleton A, buy lasix with free samples Rodriguez I.

SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 buy lasix with free samples. Doi.

Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system.

Adv Drug Deliv Rev 2012;64:614-28. 5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections.

A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27. 6.Steardo L Jr., Steardo L, Verkhratsky A.

Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health.

Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers. The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences.

Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords. Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS.

Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle.

The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability. No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience.

The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.). The dialog occurs in the 6th chapter of the epic and has over 700 verses.

In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era.

Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2). The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems.

The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus. A glaring example is the use of face masks, known to effectively slow the viral infection.

Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!.

Path of Action The second key concept is the path of action (Karma yoga, chapter 3). Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin.

Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself. Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not.

Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties.

Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6). It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%.

Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines. Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications.

These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C.

Lessons learned from the coronavirus health crisis in Madrid, Spain. How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1.

3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

Oxford, England. Oxford University Press. In Press.

4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al. Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87.

Doi. 10.1038/s41562-020-0906-x. Epub 2020 Jun 24.

5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22].

J Altern Complement Med 2020;26:10.1089/acm. 2020.0177. [doi.

10.1089/acm. 2020.0177]. 7.Gupta H, Gupta M, Bhargava S.

Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25].

Gerontology 2020:26;1-8. [doi. 10.1159/000509216].

9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29]. Eur J Pharmacol 2020;882:173329.

10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2.

12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V. The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21.

13.Keshavan MS. Pandemics and psychiatry. Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7].

Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness.

Schizophr Res 2020;218:36-7. Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

What should I watch for while using Lasix?

Visit your doctor or health care professional for regular checks on your progress. Check your blood pressure regularly. Ask your doctor or health care professional what your blood pressure should be, and when you should contact him or her. If you are a diabetic, check your blood sugar as directed.

You may need to be on a special diet while taking Lasix. Check with your doctor. Also, ask how many glasses of fluid you need to drink a day. You must not get dehydrated.

You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness until you know how this drug affects you. Do not stand or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells. Alcohol can make you more drowsy and dizzy. Avoid alcoholic drinks.

Lasix can make you more sensitive to the sun. Keep out of the sun. If you cannot avoid being in the sun, wear protective clothing and use sunscreen. Do not use sun lamps or tanning beds/booths.

Lasix horse racing

Etchells E, Ho M, Shojania lasix horse racing KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Safe 2016;25:202–6.The article has been corrected since it was published online lasix horse racing. The authors want to alert readers to the following error identified in the published version.

The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, wherein the minimum sample size has been considered as six instead of eight.For this first (convenience) sample lasix horse racing of 10 volunteer users, 5/10 (50%) completed the form without any input or instructions. The other five became frustrated and gave up. Table 1 tells you that, with an observed success lasix horse racing rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null hypothesis that your form is working at a 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention.

Fortunately, times are changing and managing alarm fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread lasix horse racing attention over the last decade, including from the news media.2–5 In the USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as well as those that are valid but not actionable or informative),7 8 better manage alarm notifications and ultimately improve patient safety. Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit. The primary project lasix horse racing goal was to reduce alarm notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons.

First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention bundle encompassed a wide variety of changes lasix horse racing including adoption of a smartphone notification system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued. Implementation of an lasix horse racing alarm notification escalation algorithm after a certain amount of time in alarm threshold violation.

Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of lasix horse racing electrode lead replacement every 24 hours. And discussion of alarm parameters on daily rounds. Third, the authors introduced a novel strategy for reducing the stress that alarms may cause patients and families by deactivating inroom alarm audio, although no outcomes were reported attributable directly lasix horse racing to this component of the intervention.This project constitutes an important contribution to the published literature.

However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management. (1) Identification of meaningful outcome lasix horse racing measures and (2) Lack of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm notifications.

The other half included second and third notifications for alarms exceeding specified delay thresholds, which were sent both to the mobile device of lasix horse racing the primary nurse and to ‘buddy’ nurses, potentially increasing alarm burden. On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the true benefit of a reduction in a subset of alarms presents complex challenges.Alarm lasix horse racing frequency is the most commonly used outcome measure in alarm research and QI projects, but reduction in alarms does not necessarily indicate improved patient safety or a highly functional alarm management system. Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms.

Unfortunately, most studies have lasix horse racing not been powered to statistically evaluate improvements in patient safety. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation). To assess change in nurses’ perceptions of alarm frequency, Pater et al conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed lasix horse racing to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue.

In fact, we currently have no widely accepted, validated tool for lasix horse racing assessing alarm fatigue.11As we look towards future evaluations of alarm management strategies, the focus needs to shift away from simply reducing the frequency of alarms to more meaningful outcome metrics. In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions. Most alarm reduction interventions have not been systematically evaluated at all or only in small studies lasix horse racing without a control group.10 11 As a result, alarm management projects tend to involve complex and costly bundles of interventions of uncertain benefit.

The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments in personnel, such as monitor ‘watchers’ to help nurses lasix horse racing identify actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit from a higher quality evidence base for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted. In addition, we need to evaluate interventions that address the full spectrum of the alarm management lasix horse racing system.

Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis has been placed on ensuring that the nurse receiving the notification is available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that nurses lasix horse racing may not always respond quickly for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response. In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do not want to engender more frequent interruptions of high-risk activities, like medication administration,18 19 because nurses feel compelled to respond more quickly to alarms.The robust QI initiative carried out by Pater et al lasix horse racing reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate.

Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities). This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..

Etchells E, Ho M, buy lasix with free samples Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Safe 2016;25:202–6.The article has been corrected since it was buy lasix with free samples published online. The authors want to alert readers to the following error identified in the published version.

The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, wherein the minimum sample size has been considered as six instead of eight.For this first (convenience) sample of 10 volunteer users, 5/10 (50%) completed the form without any input buy lasix with free samples or instructions. The other five became frustrated and gave up. Table 1 tells you that, with an observed success buy lasix with free samples rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null hypothesis that your form is working at a 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention.

Fortunately, times are changing and managing alarm fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread attention over the last decade, including from the news media.2–5 In the USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm buy lasix with free samples safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as well as those that are valid but not actionable or informative),7 8 better manage alarm notifications and ultimately improve patient safety. Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit. The primary project goal was to reduce alarm buy lasix with free samples notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons.

First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention bundle encompassed a buy lasix with free samples wide variety of changes including adoption of a smartphone notification system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued. Implementation of an alarm notification escalation algorithm after a certain amount of time in alarm buy lasix with free samples threshold violation.

Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of buy lasix with free samples electrode lead replacement every 24 hours. And discussion of alarm parameters on daily rounds. Third, the authors introduced a novel strategy for reducing the stress that alarms may cause patients and families by deactivating inroom alarm audio, although no outcomes were reported attributable directly to this buy lasix with free samples component of the intervention.This project constitutes an important contribution to the published literature.

However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management. (1) Identification of meaningful outcome buy lasix with free samples measures and (2) Lack of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm notifications.

The other half included second and third notifications for alarms exceeding specified delay thresholds, which were sent buy lasix with free samples both to the mobile device of the primary nurse and to ‘buddy’ nurses, potentially increasing alarm burden. On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the true benefit of a reduction in a subset of alarms presents complex challenges.Alarm frequency is the most commonly used outcome measure in alarm research and QI projects, buy lasix with free samples but reduction in alarms does not necessarily indicate improved patient safety or a highly functional alarm management system. Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms.

Unfortunately, most studies have not been powered to statistically evaluate improvements buy lasix with free samples in patient safety. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation). To assess change buy lasix with free samples in nurses’ perceptions of alarm frequency, Pater et al conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue.

In fact, we currently have no widely accepted, validated tool for buy lasix with free samples assessing alarm fatigue.11As we look towards future evaluations of alarm management strategies, the focus needs to shift away from simply reducing the frequency of alarms to more meaningful outcome metrics. In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions. Most alarm reduction interventions have not been systematically evaluated at all or only buy lasix with free samples in small studies without a control group.10 11 As a result, alarm management projects tend to involve complex and costly bundles of interventions of uncertain benefit.

The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments buy lasix with free samples in personnel, such as monitor ‘watchers’ to help nurses identify actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit from a higher quality evidence base for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted. In addition, we need to evaluate interventions that address the buy lasix with free samples full spectrum of the alarm management system.

Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis has been placed on ensuring that the nurse receiving the notification is available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that nurses may not always respond quickly buy lasix with free samples for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response. In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do not want to engender more frequent interruptions of high-risk activities, like medication administration,18 19 because nurses feel compelled buy lasix with free samples to respond more quickly to alarms.The robust QI initiative carried out by Pater et al reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate.

Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities). This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..

Define lasix

More than define lasix 90% of babies born with heart defects survive into adulthood. As a result, there are now more adults living with congenital heart disease than children. These adults have define lasix a chronic, lifelong condition and the European Society of Cardiology (ESC) has produced advice to give the best chance of a normal life.

The guidelines are published online today in European Heart Journal,1 and on the ESC website.2Congenital heart disease refers to any structural defect of the heart and/or great vessels (those directly connected to the heart) present at birth. Congenital heart disease affects all aspects of life, including physical and mental define lasix health, socialising, and work. Most patients are unable to exercise at the same level as their peers which, along with the awareness of having a chronic condition, affects mental wellbeing."Having a congenital heart disease, with a need for long-term follow-up and treatment, can also have an impact on social life, limit employment options and make it difficult to get insurance," said Professor Helmut Baumgartner, Chairperson of the guidelines Task Force and head of Adult Congenital and Valvular Heart Disease at the University Hospital of Münster, Germany.

"Guiding and supporting patients in all of these processes is an inherent part of their care."All adults with congenital heart disease should have at least one appointment at define lasix a specialist centre to determine how often they need to be seen. Teams at these centres should include specialist nurses, psychologists and social workers given that anxiety and depression are common concerns.Pregnancy is contraindicated in women with certain conditions such high blood pressure in the arteries of the lungs. "Pre-conception counselling is recommended for women and men to discuss the risk of the defect in define lasix offspring and the option of foetal screening," said Professor Julie De Backer, Chairperson of the guidelines Task Force and cardiologist and clinical geneticist at Ghent University Hospital, Belgium.Concerning sports, recommendations are provided for each condition.

Professor De Backer said. "All adults with congenital heart disease should be encouraged to exercise, taking into account the nature of the underlying defect and their define lasix own abilities."The guidelines state when and how to diagnose complications. This includes proactively monitoring for arrhythmias, cardiac imaging and blood tests to detect problems with heart function.Detailed recommendations are provided on how and when to treat complications.

Arrhythmias are an important cause of define lasix sickness and death and the guidelines stress the importance of correct and timely referral to a specialised treatment centre. They also list when particular treatments should be considered such as ablation (a procedure to destroy heart tissue and stop faulty electrical signals) and device implantation.For several defects, there are new recommendations for catheter-based treatment. "Catheter-based treatment should be performed by specialists in adult congenital heart define lasix disease working within a multidisciplinary team," said Professor Baumgartner.

Story Source. Materials provided by European Society of define lasix Cardiology. Note.

Content may be edited for style and define lasix length.One in five patients die within a year after the most common type of heart attack. European Society of Cardiology (ESC) treatment guidelines for non-ST-segment elevation acute coronary syndrome are published online today in European Heart Journal, and on the ESC website.Chest pain is the most common symptom, along with pain radiating to one or both arms, the neck, or jaw. Anyone experiencing these define lasix symptoms should call an ambulance immediately.

Complications include potentially deadly heart rhythm disorders (arrhythmias), which are another reason to seek urgent medical help.Treatment is aimed at the underlying cause. The main reason define lasix is fatty deposits (atherosclerosis) that become surrounded by a blood clot, narrowing the arteries supplying blood to the heart. In these cases, patients should receive blood thinners and stents to restore blood flow.

For the first time, the guidelines recommend imaging to identify other causes such as a tear in a blood vessel leading define lasix to the heart.Regarding diagnosis, there is no distinguishing change on the electrocardiogram (ECG), which may be normal. The key step is measuring a chemical in the blood called troponin. When blood flow to the heart is decreased or blocked, heart define lasix cells die, and troponin levels rise.

If levels are normal, the measurement should be repeated one hour later to rule out the diagnosis. If elevated, hospital admission is recommended to further evaluate the severity of the disease and decide the treatment strategy.Given that the main cause is related to atherosclerosis, there define lasix is a high risk of recurrence, which can also be deadly. Patients should be prescribed blood thinners and lipid lowering therapies.

"Equally important is a healthy lifestyle including smoking cessation, exercise, and a diet emphasising vegetables, fruits and whole grains while limiting saturated fat and alcohol," said Professor Jean-Philippe Collet, Chairperson of the guidelines Task Force and professor of cardiology, Sorbonne University, define lasix Paris, France.Behavioural change and adherence to medication are best achieved when patients are supported by a multidisciplinary team including cardiologists, general practitioners, nurses, dietitians, physiotherapists, psychologists, and pharmacists.The likelihood of triggering another heart attack during sexual activity is low for most patients, and regular exercise decreases this risk. Healthcare providers should ask patients about sexual activity and offer advice and counselling.Annual influenza vaccination is recommended -- especially for patients aged 65 and over -- to prevent further heart attacks and increase longevity."Women should receive equal access to care, a prompt diagnosis, and treatments at the same rate and intensity as men," said Professor Holger Thiele, Chairperson of the guidelines Task Force and medical director, Department of Internal Medicine/Cardiology, Heart Centre Leipzig, Germany. Story Source define lasix.

Materials provided by European Society of Cardiology. Note. Content may be edited for style and length.Feeling angry these days?.

New research suggests that a good night of sleep may be just what you need.This program of research comprised an analysis of diaries and lab experiments. The researchers analyzed daily diary entries from 202 college students, who tracked their sleep, daily stressors, and anger over one month. Preliminary results show that individuals reported experiencing more anger on days following less sleep than usual for them.The research team also conducted a lab experiment involving 147 community residents.

Participants were randomly assigned either to maintain their regular sleep schedule or to restrict their sleep at home by about five hours across two nights. Following this manipulation, anger was assessed during exposure to irritating noise.The experiment found that well-slept individuals adapted to noise and reported less anger after two days. In contrast, sleep-restricted individuals exhibited higher and increased anger in response to aversive noise, suggesting that losing sleep undermined emotional adaptation to frustrating circumstance.

Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger. A related experiment in which individuals reported anger following an online competitive game found similar results."The results are important because they provide strong causal evidence that sleep restriction increases anger and increases frustration over time," said Zlatan Krizan, who has a doctorate in personality and social psychology and is a professor of psychology at Iowa State University in Ames, Iowa. "Moreover, the results from the daily diary study suggest such effects translate to everyday life, as young adults reported more anger in the afternoon on days they slept less."The authors noted that the findings highlight the importance of considering specific emotional reactions such as anger and their regulation in the context of sleep disruption.

Story Source. Materials provided by American Academy of Sleep Medicine. Note.

Content may be edited for style and length.Overcoming the nation's opioid epidemic will require clinicians to look beyond opioids, new research from Oregon Health &. Science University suggests.The study reveals that among patients who participated in an in-hospital addiction medicine intervention at OHSU, three-quarters came into the hospital using more than one substance. Overall, participants used fewer substances in the months after working with the hospital-based addictions team than before.The study published in the Journal of Substance Abuse Treatment."We found that polysubstance use is the norm," said lead author Caroline King, M.P.H., a health systems researcher and current M.D./Ph.D.

Student in the OHSU School of Medicine's biomedical engineering program. "This is important because we may need to offer additional support to patients using multiple drugs. If someone with opioid use disorder also uses alcohol or methamphetamines, we miss caring for the whole person by focusing only on their opioid use."About 40% of participants reported they had abstained from using at least one substance at least a month after discharge -- a measure of success that isn't typically tracked in health system record-keeping.Researchers enrolled 486 people seen by an addiction medicine consult service while hospitalized at OHSU Hospital between 2015 and 2018, surveying them early during their stay in the hospital and then again 30 to 90 days after discharge.

advertisement Treatment of opioid use disorder can involve medication such as buprenorphine, or Suboxone, which normalizes brain function by acting on the same target in the brain as prescription opioids or heroin.However, focusing only on the opioid addiction may not adequately address the complexity of each patient."Methamphetamine use in many parts of the U.S., including Oregon, is prominent right now," said senior author Honora Englander, M.D., associate professor of medicine (hospital medicine) in the OHSU School of Medicine. "If people are using stimulants and opioids -- and we only talk about their opioid use -- there are independent harms from stimulant use combined with opioids. People may be using methamphetamines for different reasons than they use opioids."Englander leads the in-hospital addiction service, known as Project IMPACT, or Improving Addiction Care Team.The initiative brings together physicians, social workers, peer-recovery mentors and community addiction providers to address addiction when patients are admitted to the hospital.

Since its inception in 2015, the program has served more than 1,950 people hospitalized at OHSU.The national opioid epidemic spiraled out of control following widespread prescribing of powerful pain medications beginning in the 1990s. Since then, it has often been viewed as a public health crisis afflicting rural, suburban and affluent communities that are largely white.Englander said the new study suggests that a singular focus on opioids may cause clinicians to overlook complexity of issues facing many populations, including people of color, who may also use other substances."Centering on opioids centers on whiteness," Englander said. "Understanding the complexity of people's substance use patterns is really important to honoring their experience and developing systems that support their needs."Researchers say the finding further reinforces earlier research showing that hospitalization is an important time to offer treatment to people with substance use disorder, even if they are not seeking treatment for addiction when they come to the hospital.

Story Source. Materials provided by Oregon Health &. Science University.

Original written by Erik Robinson. Note. Content may be edited for style and length.Researchers from the University of Minnesota, with support from Medtronic, have developed a groundbreaking process for multi-material 3D printing of lifelike models of the heart's aortic valve and the surrounding structures that mimic the exact look and feel of a real patient.These patient-specific organ models, which include 3D-printed soft sensor arrays integrated into the structure, are fabricated using specialized inks and a customized 3D printing process.

Such models can be used in preparation for minimally invasive procedures to improve outcomes in thousands of patients worldwide.The research is published in Science Advances, a peer-reviewed scientific journal published by the American Association for the Advancement of Science (AAAS).The researchers 3D printed what is called the aortic root, the section of the aorta closest to and attached to the heart. The aortic root consists of the aortic valve and the openings for the coronary arteries. The aortic valve has three flaps, called leaflets, surrounded by a fibrous ring.

The model also included part of the left ventricle muscle and the ascending aorta."Our goal with these 3D-printed models is to reduce medical risks and complications by providing patient-specific tools to help doctors understand the exact anatomical structure and mechanical properties of the specific patient's heart," said Michael McAlpine, a University of Minnesota mechanical engineering professor and senior researcher on the study. "Physicians can test and try the valve implants before the actual procedure. The models can also help patients better understand their own anatomy and the procedure itself."This organ model was specifically designed to help doctors prepare for a procedure called a Transcatheter Aortic Valve Replacement (TAVR) in which a new valve is placed inside the patient's native aortic valve.

The procedure is used to treat a condition called aortic stenosis that occurs when the heart's aortic valve narrows and prevents the valve from opening fully, which reduces or blocks blood flow from the heart into the main artery. Aortic stenosis is one of the most common cardiovascular conditions in the elderly and affects about 2.7 million adults over the age of 75 in North America. The TAVR procedure is less invasive than open heart surgery to repair the damaged valve.

advertisement The aortic root models are made by using CT scans of the patient to match the exact shape. They are then 3D printed using specialized silicone-based inks that mechanically match the feel of real heart tissue the researchers obtained from the University of Minnesota's Visible Heart Laboratories. Commercial printers currently on the market can 3D print the shape, but use inks that are often too rigid to match the softness of real heart tissue.On the flip side, the specialized 3D printers at the University of Minnesota were able to mimic both the soft tissue components of the model, as well as the hard calcification on the valve flaps by printing an ink similar to spackling paste used in construction to repair drywall and plaster.Physicians can use the models to determine the size and placement of the valve device during the procedure.

Integrated sensors that are 3D printed within the model give physicians the electronic pressure feedback that can be used to guide and optimize the selection and positioning of the valve within the patient's anatomy.But McAlpine doesn't see this as the end of the road for these 3D-printed models."As our 3D-printing techniques continue to improve and we discover new ways to integrate electronics to mimic organ function, the models themselves may be used as artificial replacement organs," said McAlpine, who holds the Kuhrmeyer Family Chair Professorship in the University of Minnesota Department of Mechanical Engineering. "Someday maybe these 'bionic' organs can be as good as or better than their biological counterparts."In addition to McAlpine, the team included University of Minnesota researchers Ghazaleh Haghiashtiani, co-first author and a recent mechanical engineering Ph.D. Graduate who now works at Seagate.

Kaiyan Qiu, another co-first author and a former mechanical engineering postdoctoral researcher who is now an assistant professor at Washington State University. Jorge D. Zhingre Sanchez, a former biomedical engineering Ph.D.

Student who worked in the University of Minnesota's Visible Heart Laboratories who is now a senior R&D engineer at Medtronic. Zachary J. Fuenning, a mechanical engineering graduate student.

Paul A. Iaizzo, a professor of surgery in the Medical School and founding director of the U of M Visible Heart Laboratories. Priya Nair, senior scientist at Medtronic.

And Sarah E. Ahlberg, director of research &. Technology at Medtronic.This research was funded by Medtronic, the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health, and the Minnesota Discovery, Research, and InnoVation Economy (MnDRIVE) Initiative through the State of Minnesota.

Additional support was provided by University of Minnesota Interdisciplinary Doctoral Fellowship and Doctoral Dissertation Fellowship awarded to Ghazaleh Haghiashtiani..

More than 90% of buy lasix with free samples babies born with heart defects survive into adulthood. As a result, there are now more adults living with congenital heart disease than children. These adults have a chronic, lifelong condition and the European Society of Cardiology (ESC) has produced advice to give the best chance of a normal life buy lasix with free samples. The guidelines are published online today in European Heart Journal,1 and on the ESC website.2Congenital heart disease refers to any structural defect of the heart and/or great vessels (those directly connected to the heart) present at birth. Congenital heart disease affects all aspects of life, including buy lasix with free samples physical and mental health, socialising, and work.

Most patients are unable to exercise at the same level as their peers which, along with the awareness of having a chronic condition, affects mental wellbeing."Having a congenital heart disease, with a need for long-term follow-up and treatment, can also have an impact on social life, limit employment options and make it difficult to get insurance," said Professor Helmut Baumgartner, Chairperson of the guidelines Task Force and head of Adult Congenital and Valvular Heart Disease at the University Hospital of Münster, Germany. "Guiding and supporting patients in all of these processes is an inherent part buy lasix with free samples of their care."All adults with congenital heart disease should have at least one appointment at a specialist centre to determine how often they need to be seen. Teams at these centres should include specialist nurses, psychologists and social workers given that anxiety and depression are common concerns.Pregnancy is contraindicated in women with certain conditions such high blood pressure in the arteries of the lungs. "Pre-conception counselling is recommended for women and men to discuss the risk of the defect in offspring and the option of foetal screening," said Professor Julie De Backer, Chairperson of the guidelines Task Force and cardiologist and clinical geneticist at Ghent University Hospital, Belgium.Concerning sports, recommendations are provided for each buy lasix with free samples condition. Professor De Backer said.

"All adults with congenital heart disease should be encouraged to exercise, taking into account the nature of the buy lasix with free samples underlying defect and their own abilities."The guidelines state when and how to diagnose complications. This includes proactively monitoring for arrhythmias, cardiac imaging and blood tests to detect problems with heart function.Detailed recommendations are provided on how and when to treat complications. Arrhythmias are an important cause of sickness and death and the guidelines stress the importance of buy lasix with free samples correct and timely referral to a specialised treatment centre. They also list when particular treatments should be considered such as ablation (a procedure to destroy heart tissue and stop faulty electrical signals) and device implantation.For several defects, there are new recommendations for catheter-based treatment. "Catheter-based treatment should be performed by specialists in adult congenital heart disease working buy lasix with free samples within a multidisciplinary team," said Professor Baumgartner.

Story Source. Materials provided by European Society buy lasix with free samples of Cardiology. Note. Content may be edited for style and length.One in five patients die within a year after the most common type of heart attack buy lasix with free samples. European Society of Cardiology (ESC) treatment guidelines for non-ST-segment elevation acute coronary syndrome are published online today in European Heart Journal, and on the ESC website.Chest pain is the most common symptom, along with pain radiating to one or both arms, the neck, or jaw.

Anyone experiencing buy lasix with free samples these symptoms should call an ambulance immediately. Complications include potentially deadly heart rhythm disorders (arrhythmias), which are another reason to seek urgent medical help.Treatment is aimed at the underlying cause. The main reason is fatty deposits (atherosclerosis) that become buy lasix with free samples surrounded by a blood clot, narrowing the arteries supplying blood to the heart. In these cases, patients should receive blood thinners and stents to restore blood flow. For the first time, the guidelines recommend imaging to identify other causes buy lasix with free samples such as a tear in a blood vessel leading to the heart.Regarding diagnosis, there is no distinguishing change on the electrocardiogram (ECG), which may be normal.

The key step is measuring a chemical in the blood called troponin. When blood flow to the heart is decreased or blocked, heart cells die, and troponin buy lasix with free samples levels rise. If levels are normal, the measurement should be repeated one hour later to rule out the diagnosis. If elevated, hospital admission is recommended to further evaluate buy lasix with free samples the severity of the disease and decide the treatment strategy.Given that the main cause is related to atherosclerosis, there is a high risk of recurrence, which can also be deadly. Patients should be prescribed blood thinners and lipid lowering therapies.

"Equally important is a healthy lifestyle including smoking cessation, exercise, and a diet emphasising vegetables, fruits and whole grains while limiting saturated fat and alcohol," said Professor Jean-Philippe Collet, Chairperson of the guidelines Task Force and professor of cardiology, Sorbonne University, Paris, France.Behavioural change and adherence to medication are best achieved when patients are supported by a multidisciplinary team including cardiologists, general practitioners, nurses, dietitians, physiotherapists, psychologists, and pharmacists.The buy lasix with free samples likelihood of triggering another heart attack during sexual activity is low for most patients, and regular exercise decreases this risk. Healthcare providers should ask patients about sexual activity and offer advice and counselling.Annual influenza vaccination is recommended -- especially for patients aged 65 and over -- to prevent further heart attacks and increase longevity."Women should receive equal access to care, a prompt diagnosis, and treatments at the same rate and intensity as men," said Professor Holger Thiele, Chairperson of the guidelines Task Force and medical director, Department of Internal Medicine/Cardiology, Heart Centre Leipzig, Germany. Story Source buy lasix with free samples. Materials provided by European Society of Cardiology. Note.

Content may be edited for style and length.Feeling angry these days?. New research suggests that a good night of sleep may be just what you need.This program of research comprised an analysis of diaries and lab experiments. The researchers analyzed daily diary entries from 202 college students, who tracked their sleep, daily stressors, and anger over one month. Preliminary results show that individuals reported experiencing more anger on days following less sleep than usual for them.The research team also conducted a lab experiment involving 147 community residents. Participants were randomly assigned either to maintain their regular sleep schedule or to restrict their sleep at home by about five hours across two nights.

Following this manipulation, anger was assessed during exposure to irritating noise.The experiment found that well-slept individuals adapted to noise and reported less anger after two days. In contrast, sleep-restricted individuals exhibited higher and increased anger in response to aversive noise, suggesting that losing sleep undermined emotional adaptation to frustrating circumstance. Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger. A related experiment in which individuals reported anger following an online competitive game found similar results."The results are important because they provide strong causal evidence that sleep restriction increases anger and increases frustration over time," said Zlatan Krizan, who has a doctorate in personality and social psychology and is a professor of psychology at Iowa State University in Ames, Iowa. "Moreover, the results from the daily diary study suggest such effects translate to everyday life, as young adults reported more anger in the afternoon on days they slept less."The authors noted that the findings highlight the importance of considering specific emotional reactions such as anger and their regulation in the context of sleep disruption.

Story Source. Materials provided by American Academy of Sleep Medicine. Note. Content may be edited for style and length.Overcoming the nation's opioid epidemic will require clinicians to look beyond opioids, new research from Oregon Health &. Science University suggests.The study reveals that among patients who participated in an in-hospital addiction medicine intervention at OHSU, three-quarters came into the hospital using more than one substance.

Overall, participants used fewer substances in the months after working with the hospital-based addictions team than before.The study published in the Journal of Substance Abuse Treatment."We found that polysubstance use is the norm," said lead author Caroline King, M.P.H., a health systems researcher and current M.D./Ph.D. Student in the OHSU School of Medicine's biomedical engineering program. "This is important because we may need to offer additional support to patients using multiple drugs. If someone with opioid use disorder also uses alcohol or methamphetamines, we miss caring for the whole person by focusing only on their opioid use."About 40% of participants reported they had abstained from using at least one substance at least a month after discharge -- a measure of success that isn't typically tracked in health system record-keeping.Researchers enrolled 486 people seen by an addiction medicine consult service while hospitalized at OHSU Hospital between 2015 and 2018, surveying them early during their stay in the hospital and then again 30 to 90 days after discharge. advertisement Treatment of opioid use disorder can involve medication such as buprenorphine, or Suboxone, which normalizes brain function by acting on the same target in the brain as prescription opioids or heroin.However, focusing only on the opioid addiction may not adequately address the complexity of each patient."Methamphetamine use in many parts of the U.S., including Oregon, is prominent right now," said senior author Honora Englander, M.D., associate professor of medicine (hospital medicine) in the OHSU School of Medicine.

"If people are using stimulants and opioids -- and we only talk about their opioid use -- there are independent harms from stimulant use combined with opioids. People may be using methamphetamines for different reasons than they use opioids."Englander leads the in-hospital addiction service, known as Project IMPACT, or Improving Addiction Care Team.The initiative brings together physicians, social workers, peer-recovery mentors and community addiction providers to address addiction when patients are admitted to the hospital. Since its inception in 2015, the program has served more than 1,950 people hospitalized at OHSU.The national opioid epidemic spiraled out of control following widespread prescribing of powerful pain medications beginning in the 1990s. Since then, it has often been viewed as a public health crisis afflicting rural, suburban and affluent communities that are largely white.Englander said the new study suggests that a singular focus on opioids may cause clinicians to overlook complexity of issues facing many populations, including people of color, who may also use other substances."Centering on opioids centers on whiteness," Englander said. "Understanding the complexity of people's substance use patterns is really important to honoring their experience and developing systems that support their needs."Researchers say the finding further reinforces earlier research showing that hospitalization is an important time to offer treatment to people with substance use disorder, even if they are not seeking treatment for addiction when they come to the hospital.

Story Source. Materials provided by Oregon Health &. Science University. Original written by Erik Robinson. Note.

Content may be edited for style and length.Researchers from the University of Minnesota, with support from Medtronic, have developed a groundbreaking process for multi-material 3D printing of lifelike models of the heart's aortic valve and the surrounding structures that mimic the exact look and feel of a real patient.These patient-specific organ models, which include 3D-printed soft sensor arrays integrated into the structure, are fabricated using specialized inks and a customized 3D printing process. Such models can be used in preparation for minimally invasive procedures to improve outcomes in thousands of patients worldwide.The research is published in Science Advances, a peer-reviewed scientific journal published by the American Association for the Advancement of Science (AAAS).The researchers 3D printed what is called the aortic root, the section of the aorta closest to and attached to the heart. The aortic root consists of the aortic valve and the openings for the coronary arteries. The aortic valve has three flaps, called leaflets, surrounded by a fibrous ring. The model also included part of the left ventricle muscle and the ascending aorta."Our goal with these 3D-printed models is to reduce medical risks and complications by providing patient-specific tools to help doctors understand the exact anatomical structure and mechanical properties of the specific patient's heart," said Michael McAlpine, a University of Minnesota mechanical engineering professor and senior researcher on the study.

"Physicians can test and try the valve implants before the actual procedure. The models can also help patients better understand their own anatomy and the procedure itself."This organ model was specifically designed to help doctors prepare for a procedure called a Transcatheter Aortic Valve Replacement (TAVR) in which a new valve is placed inside the patient's native aortic valve. The procedure is used to treat a condition called aortic stenosis that occurs when the heart's aortic valve narrows and prevents the valve from opening fully, which reduces or blocks blood flow from the heart into the main artery. Aortic stenosis is one of the most common cardiovascular conditions in the elderly and affects about 2.7 million adults over the age of 75 in North America. The TAVR procedure is less invasive than open heart surgery to repair the damaged valve.

advertisement The aortic root models are made by using CT scans of the patient to match the exact shape. They are then 3D printed using specialized silicone-based inks that mechanically match the feel of real heart tissue the researchers obtained from the University of Minnesota's Visible Heart Laboratories. Commercial printers currently on the market can 3D print the shape, but use inks that are often too rigid to match the softness of real heart tissue.On the flip side, the specialized 3D printers at the University of Minnesota were able to mimic both the soft tissue components of the model, as well as the hard calcification on the valve flaps by printing an ink similar to spackling paste used in construction to repair drywall and plaster.Physicians can use the models to determine the size and placement of the valve device during the procedure. Integrated sensors that are 3D printed within the model give physicians the electronic pressure feedback that can be used to guide and optimize the selection and positioning of the valve within the patient's anatomy.But McAlpine doesn't see this as the end of the road for these 3D-printed models."As our 3D-printing techniques continue to improve and we discover new ways to integrate electronics to mimic organ function, the models themselves may be used as artificial replacement organs," said McAlpine, who holds the Kuhrmeyer Family Chair Professorship in the University of Minnesota Department of Mechanical Engineering. "Someday maybe these 'bionic' organs can be as good as or better than their biological counterparts."In addition to McAlpine, the team included University of Minnesota researchers Ghazaleh Haghiashtiani, co-first author and a recent mechanical engineering Ph.D.

Graduate who now works at Seagate. Kaiyan Qiu, another co-first author and a former mechanical engineering postdoctoral researcher who is now an assistant professor at Washington State University. Jorge D. Zhingre Sanchez, a former biomedical engineering Ph.D. Student who worked in the University of Minnesota's Visible Heart Laboratories who is now a senior R&D engineer at Medtronic.

Zachary J. Fuenning, a mechanical engineering graduate student. Paul A. Iaizzo, a professor of surgery in the Medical School and founding director of the U of M Visible Heart Laboratories. Priya Nair, senior scientist at Medtronic.

And Sarah E. Ahlberg, director of research &. Technology at Medtronic.This research was funded by Medtronic, the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health, and the Minnesota Discovery, Research, and InnoVation Economy (MnDRIVE) Initiative through the State of Minnesota. Additional support was provided by University of Minnesota Interdisciplinary Doctoral Fellowship and Doctoral Dissertation Fellowship awarded to Ghazaleh Haghiashtiani..

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Aug. 29, 2020 -- Chadwick Boseman, the star of the 2018 Marvel Studios megahit Black Panther, died of colon cancer Friday. He was 43.

Boseman, who was diagnosed 4 years ago, had kept his condition a secret. He filmed his recent movies ''during and between countless surgeries and chemotherapy," according to a statement issued on his Twitter account. When the actor was diagnosed in 2016, the cancer was at stage III -- meaning it had already grown through the colon wall -- but then progressed to the more lethal stage IV, meaning it had spread beyond his colon.

Messages of condolences and the hashtag #Wakandaforever, referring to the fictional African nation in the Black Panther film, flooded social media Friday evening. Oprah tweeted. "What a gentle gifted SOUL.

Showing us all that Greatness in between surgeries and chemo. The courage, the strength, the Power it takes to do that. This is what Dignity looks like.

" Marvel Studios tweeted. "Your legacy will live on forever." Boseman was also known for his role as Jackie Robinson in the movie 42. Coincidentally, Friday was Major League Baseball's Jackie Robinson Day, where every player on every team wears Robinson's number 42 on their jerseys.

Boseman's other starring roles include portraying James Brown in Get on Up and U.S. Supreme Court Justice Thurgood Marshall in Marshall. But his role as King T'Challa in Black Panther, the super hero protagonist, made him an icon and an inspiration.

About Colon Cancer Boseman's death reflects a troubling recent trend, says Mark Hanna, MD, a colorectal surgeon at City of Hope, a comprehensive cancer center near Los Angeles. "We have noticed an increasing incidence of colorectal cancer in young adults," says Hanna, who did not treat Boseman. "I've seen patients as young as their early 20s." About 104,000 cases of colon cancer will be diagnosed this year, according to American Cancer Society estimates, and another 43,000 cases of rectal cancer will be diagnosed.

About 12% of those, or 18,000 cases, will be in people under age 50. As the rates have declined in older adults due to screening, rates in young adults have steadily risen. Younger patients are often diagnosed at a later stage than older adults, Hanna says, because patients and even their doctors don't think about the possibility of colon cancer.

Because it is considered a cancer affecting older adults, many younger people may brush off the symptoms or delay getting medical attention, Hanna says. In a survey of 885 colorectal cancer patients conducted by Colorectal Cancer Alliance earlier this year, 75% said they visited two or more doctors before getting their diagnosis, and 11% went to 10 or more before finding out. If found early, colon cancer is curable, Hanna says.

About 50% of those with colon cancer will be diagnosed at stage I or II, which is considered localized disease, he says. "The majority have a very good prognosis." The 5-year survival rate is about 90% for both stage I and II. But when it progresses to stage III, the cancer has begun to grow into surrounding tissues and the lymph nodes, Hanna says, and the survival rate for 5 years drops to 75%.

About 25% of patients are diagnosed at stage III, he says. If the diagnosis is made at stage IV, the 5-year survival rate drops to about 10% or 15%, he says. Experts have been trying to figure out why more young adults are getting colon cancer and why some do so poorly.

"Traditionally we thought that patients who are older would have a worse outlook," Hanna says, partly because they tend to have other medical conditions too. Some experts say that younger patients might have more ''genetically aggressive disease," Hanna says. "Our understanding of colorectal cancer is becoming more nuanced, and we know that not all forms are the same." For instance, he says, testing is done for specific genetic mutations that have been tied to colon cancer.

"It's not just about finding the mutations, but finding the drug that targets [that form] best." Paying Attention to Red Flags "If you have any of what we call the red flag signs, do not ignore your symptoms no matter what your age is," Hanna says. Those are. In 2018, the American Cancer Society changed its guidelines for screening, recommending those at average risk start at age 45, not 50.

The screening can be stool-based testing, such as a fecal occult blood test, or visual, such as a colonoscopy. Hanna says he orders a colonoscopy if the symptoms suggest colon cancer, regardless of a patient's age. Family history of colorectal cancer is a risk factor, as are being obese or overweight, being sedentary, and eating lots of red meat.

Sources Mark Hanna, MD, colorectal surgeon and assistant clinical professor of surgery, City of Hope, Los Angeles. American Cancer Society. "Key Statistics for Colorectal Cancer." Twitter statement.

Chadwick Boseman. American Cancer Society. "Colorectal Cancer Risk Factors." American Cancer Society.

'"Colorectal Cancer Rates Rise in Younger Adults." American Society of Clinical Oncology annual meeting, May 29-31, 2020. American Cancer Society "Survival Rates for Colorectal Cancer." American Cancer Society. "Colorectal Cancer Facts &.

Figures. 2017-2019." © 2020 WebMD, LLC. All rights reserved.FRIDAY, Aug.

28, 2020 (HealthDay News) -- As many as 20% of Americans don't believe in vaccines, a new study finds. Misinformed vaccine beliefs drive opposition to public vaccine policies even more than politics, education, religion or other factors, researchers say. The findings are based on a survey of nearly 2,000 U.S.

Adults done in 2019, during the largest measles outbreak in 25 years. The researchers, from the Annenberg Public Policy Center (APPC) of the University of Pennsylvania, found that negative misperceptions about vaccinations. reduced the likelihood of supporting mandatory childhood vaccines by 70%, reduced the likelihood of opposing religious exemptions by 66%, reduced the likelihood of opposing personal belief exemptions by 79%.

"There are real implications here for a vaccine for COVID-19," lead author Dominik Stecula said in an APPC news release. He conducted the research while at APPC and is now an assistant professor of political science at Colorado State University. "The negative vaccine beliefs we examined aren't limited only to the measles, mumps and rubella [MMR] vaccine, but are general attitudes about vaccination." Stecula called for an education campaign by public health professionals and journalists, among others, to preemptively correct misinformation and prepare the public to accept a COVID-19 vaccine.

Overall, there was strong support for vaccination policies. 72% strongly or somewhat supported mandatory childhood vaccination, 60% strongly or somewhat opposed religious exemptions, 66% strongly or somewhat opposed vaccine exemptions based on personal beliefs. "On the one hand, these are big majorities.

Well above 50% of Americans support mandatory childhood vaccinations and oppose religious and personal belief exemptions to vaccination," said co-author Ozan Kuru, a former APPC researcher, now an assistant professor of communications at the National University of Singapore. "Still, we need a stronger consensus in the public to bolster pro-vaccine attitudes and legislation and thus achieve community immunity," he added in the release. A previous study from the 2018-2019 measles outbreak found that people who rely on social media were more likely to be misinformed about vaccines.

And a more recent one found that people who got information from social media or conservative news outlets at the start of the COVID-19 pandemic were more likely to be misinformed about how to prevent infection and hold conspiracy theories about it. With the coronavirus pandemic still raging, the number of Americans needed to be vaccinated to achieve community-wide immunity is not known, the researchers said. The findings were recently published online in the American Journal of Public Health.By Robert Preidt HealthDay Reporter FRIDAY, Aug.

28, 2020 (HealthDay News) -- Breastfeeding mothers are unlikely to transmit the new coronavirus to their babies via their milk, researchers say. No cases of an infant contracting COVID-19 from breast milk have been documented, but questions about the potential risk remain. Researchers examined 64 samples of breast milk collected from 18 women across the United States who were infected with the new coronavirus (SARS-CoV-2) that causes COVID-19.

One sample tested positive for coronavirus RNA, but follow-up tests showed that the virus couldn't replicate and therefore, couldn't infect the breastfed infant, according to the study recently published online in the Journal of the American Medical Association. "Detection of viral RNA does not equate to infection. It has to grow and multiply in order to be infectious and we did not find that in any of our samples," said study author Christina Chambers, a professor of pediatrics at the University of California, San Diego.

She is also director of the Mommy's Milk Human Milk Research Biorepository. "Our findings suggest breast milk itself is not likely a source of infection for the infant," Chambers said in a UCSD news release. To prevent transmission of the virus while breastfeeding, wearing a mask, hand-washing and sterilizing pumping equipment after each use are recommended.

"We hope our results and future studies will give women the reassurance needed for them to breastfeed. Human milk provides invaluable benefits to mom and baby," said co-author Dr. Grace Aldrovandi, chief of the Division of Infectious Diseases at UCLA Mattel Children's Hospital in Los Angeles.

WebMD News from HealthDay Sources SOURCE. University of California, San Diego, news release, Aug. 19, 2020 Copyright © 2013-2020 HealthDay.

All rights reserved.Nursing home staff will have to be tested regularly for COVID-19, and facilities that fail to do so will face fines, the Trump administration said Tuesday. Even though they account for less than 1% of the nation's population, long-term care facilities account for 42% of COVID-19 deaths in the United States, the Associated Press reported. There have been more than 70,000 deaths in U.S.

Nursing homes, according to the COVID Tracking Project. It's been months since the White House first urged governors to test all nursing home residents and staff, the AP reported. WebMD News from HealthDay Copyright © 2013-2020 HealthDay.

All rights reserved.August 28, 2020 -- Alcohol-based hand sanitizers that are packaged in containers that look like food items or drinks could cause injury or death if ingested, according to a new warning the FDA issued Thursday. Hand sanitizers are being packaged in beer cans, water bottles, juice bottles, vodka bottles and children’s food pouches, the FDA said. Some sanitizers also contain flavors, such as chocolate or raspberry, which could cause confusion.

€œI am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages,” Stephen Hahn, MD, the FDA commissioner, said in a statement. Accidentally drinking hand sanitizer — even a small amount — is potentially lethal to children. €œThese products could confuse consumers into accidentally ingesting a potentially deadly product,” he said.

€œIt’s dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning.” For example, the FDA received a report about a consumer who purchased a bottle that looked like drinkable water but was actually hand sanitizer. In another report, a retailer informed the agency about a hand sanitizer product that was marketed in a pouch that looks like a children’s snack and had cartoons on it. Meanwhile, the FDA's warning list about dangerous hand sanitizers containing methanol continues to grow as some people are drinking the sanitizers to get an alcohol high.

Others have believed a rumor, circulated online, that drinking the highly potent and toxic alcohol can disinfect the body, protecting them from COVID-19 infection. Earlier this month, the FDA also issued a warning about hand sanitizers contaminated with 1-propanol. Ingesting 1-propanol can cause central nervous system depression, which can be fatal, the agency says.

Symptoms of 1-propanol exposure can include confusion, decreased consciousness, and slowed pulse and breathing. One brand of sanitizer, Harmonic Nature S de RL de MI of Mexico, are labeled to contain ethanol or isopropyl alcohol but have tested positive for 1-propanol contamination. Poison control centers and state health departments have reported an increasing number of adverse events associated with hand sanitizer ingestion, including heart issues, nervous system problems, hospitalizations and deaths, according to the statement.

The FDA encouraged consumers and health care professionals to report issues to the MedWatch Adverse Event Reporting program. The agency is working with manufacturers to recall confusing and dangerous products and is encouraging retailers to remove some products from shelves. The FDA is also updating its list of hand sanitizer products that consumers should avoid.

€œManufacturers should be vigilant about packaging and marketing their hand sanitizers in food or drink packages in an effort to mitigate any potential inadvertent use by consumers,” Hahn said.More than 90% of babies born with heart defects survive into adulthood. As a result, there are now more adults living with congenital heart disease than children. These adults have a chronic, lifelong condition and the European Society of Cardiology (ESC) has produced advice to give the best chance of a normal life.

The guidelines are published online today in European Heart Journal,1 and on the ESC website.2Congenital heart disease refers to any structural defect of the heart and/or great vessels (those directly connected to the heart) present at birth. Congenital heart disease affects all aspects of life, including physical and mental health, socialising, and work. Most patients are unable to exercise at the same level as their peers which, along with the awareness of having a chronic condition, affects mental wellbeing."Having a congenital heart disease, with a need for long-term follow-up and treatment, can also have an impact on social life, limit employment options and make it difficult to get insurance," said Professor Helmut Baumgartner, Chairperson of the guidelines Task Force and head of Adult Congenital and Valvular Heart Disease at the University Hospital of Münster, Germany.

"Guiding and supporting patients in all of these processes is an inherent part of their care."All adults with congenital heart disease should have at least one appointment at a specialist centre to determine how often they need to be seen. Teams at these centres should include specialist nurses, psychologists and social workers given that anxiety and depression are common concerns.Pregnancy is contraindicated in women with certain conditions such high blood pressure in the arteries of the lungs. "Pre-conception counselling is recommended for women and men to discuss the risk of the defect in offspring and the option of foetal screening," said Professor Julie De Backer, Chairperson of the guidelines Task Force and cardiologist and clinical geneticist at Ghent University Hospital, Belgium.Concerning sports, recommendations are provided for each condition.

Professor De Backer said. "All adults with congenital heart disease should be encouraged to exercise, taking into account the nature of the underlying defect and their own abilities."The guidelines state when and how to diagnose complications. This includes proactively monitoring for arrhythmias, cardiac imaging and blood tests to detect problems with heart function.Detailed recommendations are provided on how and when to treat complications.

Arrhythmias are an important cause of sickness and death and the guidelines stress the importance of correct and timely referral to a specialised treatment centre. They also list when particular treatments should be considered such as ablation (a procedure to destroy heart tissue and stop faulty electrical signals) and device implantation.For several defects, there are new recommendations for catheter-based treatment. "Catheter-based treatment should be performed by specialists in adult congenital heart disease working within a multidisciplinary team," said Professor Baumgartner.

Story Source. Materials provided by European Society of Cardiology. Note.

Content may be edited for style and length.One in five patients die within a year after the most common type of heart attack. European Society of Cardiology (ESC) treatment guidelines for non-ST-segment elevation acute coronary syndrome are published online today in European Heart Journal, and on the ESC website.Chest pain is the most common symptom, along with pain radiating to one or both arms, the neck, or jaw. Anyone experiencing these symptoms should call an ambulance immediately.

Complications include potentially deadly heart rhythm disorders (arrhythmias), which are another reason to seek urgent medical help.Treatment is aimed at the underlying cause. The main reason is fatty deposits (atherosclerosis) that become surrounded by a blood clot, narrowing the arteries supplying blood to the heart. In these cases, patients should receive blood thinners and stents to restore blood flow.

For the first time, the guidelines recommend imaging to identify other causes such as a tear in a blood vessel leading to the heart.Regarding diagnosis, there is no distinguishing change on the electrocardiogram (ECG), which may be normal. The key step is measuring a chemical in the blood called troponin. When blood flow to the heart is decreased or blocked, heart cells die, and troponin levels rise.

If levels are normal, the measurement should be repeated one hour later to rule out the diagnosis. If elevated, hospital admission is recommended to further evaluate the severity of the disease and decide the treatment strategy.Given that the main cause is related to atherosclerosis, there is a high risk of recurrence, which can also be deadly. Patients should be prescribed blood thinners and lipid lowering therapies.

"Equally important is a healthy lifestyle including smoking cessation, exercise, and a diet emphasising vegetables, fruits and whole grains while limiting saturated fat and alcohol," said Professor Jean-Philippe Collet, Chairperson of the guidelines Task Force and professor of cardiology, Sorbonne University, Paris, France.Behavioural change and adherence to medication are best achieved when patients are supported by a multidisciplinary team including cardiologists, general practitioners, nurses, dietitians, physiotherapists, psychologists, and pharmacists.The likelihood of triggering another heart attack during sexual activity is low for most patients, and regular exercise decreases this risk. Healthcare providers should ask patients about sexual activity and offer advice and counselling.Annual influenza vaccination is recommended -- especially for patients aged 65 and over -- to prevent further heart attacks and increase longevity."Women should receive equal access to care, a prompt diagnosis, and treatments at the same rate and intensity as men," said Professor Holger Thiele, Chairperson of the guidelines Task Force and medical director, Department of Internal Medicine/Cardiology, Heart Centre Leipzig, Germany. Story Source.

Materials provided by European Society of Cardiology. Note. Content may be edited for style and length.Feeling angry these days?.

New research suggests that a good night of sleep may be just what you need.This program of research comprised an analysis of diaries and lab experiments. The researchers analyzed daily diary entries from 202 college students, who tracked their sleep, daily stressors, and anger over one month. Preliminary results show that individuals reported experiencing more anger on days following less sleep than usual for them.The research team also conducted a lab experiment involving 147 community residents.

Participants were randomly assigned either to maintain their regular sleep schedule or to restrict their sleep at home by about five hours across two nights. Following this manipulation, anger was assessed during exposure to irritating noise.The experiment found that well-slept individuals adapted to noise and reported less anger after two days. In contrast, sleep-restricted individuals exhibited higher and increased anger in response to aversive noise, suggesting that losing sleep undermined emotional adaptation to frustrating circumstance.

Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger. A related experiment in which individuals reported anger following an online competitive game found similar results."The results are important because they provide strong causal evidence that sleep restriction increases anger and increases frustration over time," said Zlatan Krizan, who has a doctorate in personality and social psychology and is a professor of psychology at Iowa State University in Ames, Iowa. "Moreover, the results from the daily diary study suggest such effects translate to everyday life, as young adults reported more anger in the afternoon on days they slept less."The authors noted that the findings highlight the importance of considering specific emotional reactions such as anger and their regulation in the context of sleep disruption.

Story Source. Materials provided by American Academy of Sleep Medicine. Note.

Content may be edited for style and length.Overcoming the nation's opioid epidemic will require clinicians to look beyond opioids, new research from Oregon Health &. Science University suggests.The study reveals that among patients who participated in an in-hospital addiction medicine intervention at OHSU, three-quarters came into the hospital using more than one substance. Overall, participants used fewer substances in the months after working with the hospital-based addictions team than before.The study published in the Journal of Substance Abuse Treatment."We found that polysubstance use is the norm," said lead author Caroline King, M.P.H., a health systems researcher and current M.D./Ph.D.

Student in the OHSU School of Medicine's biomedical engineering program. "This is important because we may need to offer additional support to patients using multiple drugs. If someone with opioid use disorder also uses alcohol or methamphetamines, we miss caring for the whole person by focusing only on their opioid use."About 40% of participants reported they had abstained from using at least one substance at least a month after discharge -- a measure of success that isn't typically tracked in health system record-keeping.Researchers enrolled 486 people seen by an addiction medicine consult service while hospitalized at OHSU Hospital between 2015 and 2018, surveying them early during their stay in the hospital and then again 30 to 90 days after discharge.

advertisement Treatment of opioid use disorder can involve medication such as buprenorphine, or Suboxone, which normalizes brain function by acting on the same target in the brain as prescription opioids or heroin.However, focusing only on the opioid addiction may not adequately address the complexity of each patient."Methamphetamine use in many parts of the U.S., including Oregon, is prominent right now," said senior author Honora Englander, M.D., associate professor of medicine (hospital medicine) in the OHSU School of Medicine. "If people are using stimulants and opioids -- and we only talk about their opioid use -- there are independent harms from stimulant use combined with opioids. People may be using methamphetamines for different reasons than they use opioids."Englander leads the in-hospital addiction service, known as Project IMPACT, or Improving Addiction Care Team.The initiative brings together physicians, social workers, peer-recovery mentors and community addiction providers to address addiction when patients are admitted to the hospital.

Since its inception in 2015, the program has served more than 1,950 people hospitalized at OHSU.The national opioid epidemic spiraled out of control following widespread prescribing of powerful pain medications beginning in the 1990s. Since then, it has often been viewed as a public health crisis afflicting rural, suburban and affluent communities that are largely white.Englander said the new study suggests that a singular focus on opioids may cause clinicians to overlook complexity of issues facing many populations, including people of color, who may also use other substances."Centering on opioids centers on whiteness," Englander said. "Understanding the complexity of people's substance use patterns is really important to honoring their experience and developing systems that support their needs."Researchers say the finding further reinforces earlier research showing that hospitalization is an important time to offer treatment to people with substance use disorder, even if they are not seeking treatment for addiction when they come to the hospital.

Story Source. Materials provided by Oregon Health &. Science University.

Original written by Erik Robinson. Note. Content may be edited for style and length.Researchers from the University of Minnesota, with support from Medtronic, have developed a groundbreaking process for multi-material 3D printing of lifelike models of the heart's aortic valve and the surrounding structures that mimic the exact look and feel of a real patient.These patient-specific organ models, which include 3D-printed soft sensor arrays integrated into the structure, are fabricated using specialized inks and a customized 3D printing process.

Such models can be used in preparation for minimally invasive procedures to improve outcomes in thousands of patients worldwide.The research is published in Science Advances, a peer-reviewed scientific journal published by the American Association for the Advancement of Science (AAAS).The researchers 3D printed what is called the aortic root, the section of the aorta closest to and attached to the heart. The aortic root consists of the aortic valve and the openings for the coronary arteries. The aortic valve has three flaps, called leaflets, surrounded by a fibrous ring.

The model also included part of the left ventricle muscle and the ascending aorta."Our goal with these 3D-printed models is to reduce medical risks and complications by providing patient-specific tools to help doctors understand the exact anatomical structure and mechanical properties of the specific patient's heart," said Michael McAlpine, a University of Minnesota mechanical engineering professor and senior researcher on the study. "Physicians can test and try the valve implants before the actual procedure. The models can also help patients better understand their own anatomy and the procedure itself."This organ model was specifically designed to help doctors prepare for a procedure called a Transcatheter Aortic Valve Replacement (TAVR) in which a new valve is placed inside the patient's native aortic valve.

The procedure is used to treat a condition called aortic stenosis that occurs when the heart's aortic valve narrows and prevents the valve from opening fully, which reduces or blocks blood flow from the heart into the main artery. Aortic stenosis is one of the most common cardiovascular conditions in the elderly and affects about 2.7 million adults over the age of 75 in North America. The TAVR procedure is less invasive than open heart surgery to repair the damaged valve.

advertisement The aortic root models are made by using CT scans of the patient to match the exact shape. They are then 3D printed using specialized silicone-based inks that mechanically match the feel of real heart tissue the researchers obtained from the University of Minnesota's Visible Heart Laboratories. Commercial printers currently on the market can 3D print the shape, but use inks that are often too rigid to match the softness of real heart tissue.On the flip side, the specialized 3D printers at the University of Minnesota were able to mimic both the soft tissue components of the model, as well as the hard calcification on the valve flaps by printing an ink similar to spackling paste used in construction to repair drywall and plaster.Physicians can use the models to determine the size and placement of the valve device during the procedure.

Integrated sensors that are 3D printed within the model give physicians the electronic pressure feedback that can be used to guide and optimize the selection and positioning of the valve within the patient's anatomy.But McAlpine doesn't see this as the end of the road for these 3D-printed models."As our 3D-printing techniques continue to improve and we discover new ways to integrate electronics to mimic organ function, the models themselves may be used as artificial replacement organs," said McAlpine, who holds the Kuhrmeyer Family Chair Professorship in the University of Minnesota Department of Mechanical Engineering. "Someday maybe these 'bionic' organs can be as good as or better than their biological counterparts."In addition to McAlpine, the team included University of Minnesota researchers Ghazaleh Haghiashtiani, co-first author and a recent mechanical engineering Ph.D. Graduate who now works at Seagate.

Kaiyan Qiu, another co-first author and a former mechanical engineering postdoctoral researcher who is now an assistant professor at Washington State University. Jorge D. Zhingre Sanchez, a former biomedical engineering Ph.D.

Student who worked in the University of Minnesota's Visible Heart Laboratories who is now a senior R&D engineer at Medtronic. Zachary J. Fuenning, a mechanical engineering graduate student.

Paul A. Iaizzo, a professor of surgery in the Medical School and founding director of the U of M Visible Heart Laboratories. Priya Nair, senior scientist at Medtronic.

And Sarah E. Ahlberg, director of research &. Technology at Medtronic.This research was funded by Medtronic, the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health, and the Minnesota Discovery, Research, and InnoVation Economy (MnDRIVE) Initiative through the State of Minnesota.

Additional support was provided by University of Minnesota Interdisciplinary Doctoral Fellowship and Doctoral Dissertation Fellowship awarded to Ghazaleh Haghiashtiani..

Aug. 29, 2020 -- Chadwick Boseman, the star of the 2018 Marvel Studios megahit Black Panther, died of colon cancer Friday. He was 43.

Boseman, who was diagnosed 4 years ago, had kept his condition a secret. He filmed his recent movies ''during and between countless surgeries and chemotherapy," according to a statement issued on his Twitter account. When the actor was diagnosed in 2016, the cancer was at stage III -- meaning it had already grown through the colon wall -- but then progressed to the more lethal stage IV, meaning it had spread beyond his colon.

Messages of condolences and the hashtag #Wakandaforever, referring to the fictional African nation in the Black Panther film, flooded social media Friday evening. Oprah tweeted. "What a gentle gifted SOUL.

Showing us all that Greatness in between surgeries and chemo. The courage, the strength, the Power it takes to do that. This is what Dignity looks like.

" Marvel Studios tweeted. "Your legacy will live on forever." Boseman was also known for his role as Jackie Robinson in the movie 42. Coincidentally, Friday was Major League Baseball's Jackie Robinson Day, where every player on every team wears Robinson's number 42 on their jerseys.

Boseman's other starring roles include portraying James Brown in Get on Up and U.S. Supreme Court Justice Thurgood Marshall in Marshall. But his role as King T'Challa in Black Panther, the super hero protagonist, made him an icon and an inspiration.

About Colon Cancer Boseman's death reflects a troubling recent trend, says Mark Hanna, MD, a colorectal surgeon at City of Hope, a comprehensive cancer center near Los Angeles. "We have noticed an increasing incidence of colorectal cancer in young adults," says Hanna, who did not treat Boseman. "I've seen patients as young as their early 20s." About 104,000 cases of colon cancer will be diagnosed this year, according to American Cancer Society estimates, and another 43,000 cases of rectal cancer will be diagnosed.

About 12% of those, or 18,000 cases, will be in people under age 50. As the rates have declined in older adults due to screening, rates in young adults have steadily risen. Younger patients are often diagnosed at a later stage than older adults, Hanna says, because patients and even their doctors don't think about the possibility of colon cancer.

Because it is considered a cancer affecting older adults, many younger people may brush off the symptoms or delay getting medical attention, Hanna says. In a survey of 885 colorectal cancer patients conducted by Colorectal Cancer Alliance earlier this year, 75% said they visited two or more doctors before getting their diagnosis, and 11% went to 10 or more before finding out. If found early, colon cancer is curable, Hanna says.

About 50% of those with colon cancer will be diagnosed at stage I or II, which is considered localized disease, he says. "The majority have a very good prognosis." The 5-year survival rate is about 90% for both stage I and II. But when it progresses to stage III, the cancer has begun to grow into surrounding tissues and the lymph nodes, Hanna says, and the survival rate for 5 years drops to 75%.

About 25% of patients are diagnosed at stage III, he says. If the diagnosis is made at stage IV, the 5-year survival rate drops to about 10% or 15%, he says. Experts have been trying to figure out why more young adults are getting colon cancer and why some do so poorly.

"Traditionally we thought that patients who are older would have a worse outlook," Hanna says, partly because they tend to have other medical conditions too. Some experts say that younger patients might have more ''genetically aggressive disease," Hanna says. "Our understanding of colorectal cancer is becoming more nuanced, and we know that not all forms are the same." For instance, he says, testing is done for specific genetic mutations that have been tied to colon cancer.

"It's not just about finding the mutations, but finding the drug that targets [that form] best." Paying Attention to Red Flags "If you have any of what we call the red flag signs, do not ignore your symptoms no matter what your age is," Hanna says. Those are. In 2018, the American Cancer Society changed its guidelines for screening, recommending those at average risk start at age 45, not 50.

The screening can be stool-based testing, such as a fecal occult blood test, or visual, such as a colonoscopy. Hanna says he orders a colonoscopy if the symptoms suggest colon cancer, regardless of a patient's age. Family history of colorectal cancer is a risk factor, as are being obese or overweight, being sedentary, and eating lots of red meat.

Sources Mark Hanna, MD, colorectal surgeon and assistant clinical professor of surgery, City of Hope, Los Angeles. American Cancer Society. "Key Statistics for Colorectal Cancer." Twitter statement.

Chadwick Boseman. American Cancer Society. "Colorectal Cancer Risk Factors." American Cancer Society.

'"Colorectal Cancer Rates Rise in Younger Adults." American Society of Clinical Oncology annual meeting, May 29-31, 2020. American Cancer Society "Survival Rates for Colorectal Cancer." American Cancer Society. "Colorectal Cancer Facts &.

Figures. 2017-2019." © 2020 WebMD, LLC. All rights reserved.FRIDAY, Aug.

28, 2020 (HealthDay News) -- As many as 20% of Americans don't believe in vaccines, a new study finds. Misinformed vaccine beliefs drive opposition to public vaccine policies even more than politics, education, religion or other factors, researchers say. The findings are based on a survey of nearly 2,000 U.S.

Adults done in 2019, during the largest measles outbreak in 25 years. The researchers, from the Annenberg Public Policy Center (APPC) of the University of Pennsylvania, found that negative misperceptions about vaccinations. reduced the likelihood of supporting mandatory childhood vaccines by 70%, reduced the likelihood of opposing religious exemptions by 66%, reduced the likelihood of opposing personal belief exemptions by 79%.

"There are real implications here for a vaccine for COVID-19," lead author Dominik Stecula said in an APPC news release. He conducted the research while at APPC and is now an assistant professor of political science at Colorado State University. "The negative vaccine beliefs we examined aren't limited only to the measles, mumps and rubella [MMR] vaccine, but are general attitudes about vaccination." Stecula called for an education campaign by public health professionals and journalists, among others, to preemptively correct misinformation and prepare the public to accept a COVID-19 vaccine.

Overall, there was strong support for vaccination policies. 72% strongly or somewhat supported mandatory childhood vaccination, 60% strongly or somewhat opposed religious exemptions, 66% strongly or somewhat opposed vaccine exemptions based on personal beliefs. "On the one hand, these are big majorities.

Well above 50% of Americans support mandatory childhood vaccinations and oppose religious and personal belief exemptions to vaccination," said co-author Ozan Kuru, a former APPC researcher, now an assistant professor of communications at the National University of Singapore. "Still, we need a stronger consensus in the public to bolster pro-vaccine attitudes and legislation and thus achieve community immunity," he added in the release. A previous study from the 2018-2019 measles outbreak found that people who rely on social media were more likely to be misinformed about vaccines.

And a more recent one found that people who got information from social media or conservative news outlets at the start of the COVID-19 pandemic were more likely to be misinformed about how to prevent infection and hold conspiracy theories about it. With the coronavirus pandemic still raging, the number of Americans needed to be vaccinated to achieve community-wide immunity is not known, the researchers said. The findings were recently published online in the American Journal of Public Health.By Robert Preidt HealthDay Reporter FRIDAY, Aug.

28, 2020 (HealthDay News) -- Breastfeeding mothers are unlikely to transmit the new coronavirus to their babies via their milk, researchers say. No cases of an infant contracting COVID-19 from breast milk have been documented, but questions about the potential risk remain. Researchers examined 64 samples of breast milk collected from 18 women across the United States who were infected with the new coronavirus (SARS-CoV-2) that causes COVID-19.

One sample tested positive for coronavirus RNA, but follow-up tests showed that the virus couldn't replicate and therefore, couldn't infect the breastfed infant, according to the study recently published online in the Journal of the American Medical Association. "Detection of viral RNA does not equate to infection. It has to grow and multiply in order to be infectious and we did not find that in any of our samples," said study author Christina Chambers, a professor of pediatrics at the University of California, San Diego.

She is also director of the Mommy's Milk Human Milk Research Biorepository. "Our findings suggest breast milk itself is not likely a source of infection for the infant," Chambers said in a UCSD news release. To prevent transmission of the virus while breastfeeding, wearing a mask, hand-washing and sterilizing pumping equipment after each use are recommended.

"We hope our results and future studies will give women the reassurance needed for them to breastfeed. Human milk provides invaluable benefits to mom and baby," said co-author Dr. Grace Aldrovandi, chief of the Division of Infectious Diseases at UCLA Mattel Children's Hospital in Los Angeles.

WebMD News from HealthDay Sources SOURCE. University of California, San Diego, news release, Aug. 19, 2020 Copyright © 2013-2020 HealthDay.

All rights reserved.Nursing home staff will have to be tested regularly for COVID-19, and facilities that fail to do so will face fines, the Trump administration said Tuesday. Even though they account for less than 1% of the nation's population, long-term care facilities account for 42% of COVID-19 deaths in the United States, the Associated Press reported. There have been more than 70,000 deaths in U.S.

Nursing homes, according to the COVID Tracking Project. It's been months since the White House first urged governors to test all nursing home residents and staff, the AP reported. WebMD News from HealthDay Copyright © 2013-2020 HealthDay.

All rights reserved.August 28, 2020 -- Alcohol-based hand sanitizers that are packaged in containers that look like food items or drinks could cause injury or death if ingested, according to a new warning the FDA issued Thursday. Hand sanitizers are being packaged in beer cans, water bottles, juice bottles, vodka bottles and children’s food pouches, the FDA said. Some sanitizers also contain flavors, such as chocolate or raspberry, which could cause confusion.

€œI am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages,” Stephen Hahn, MD, the FDA commissioner, said in a statement. Accidentally drinking hand sanitizer — even a small amount — is potentially lethal to children. €œThese products could confuse consumers into accidentally ingesting a potentially deadly product,” he said.

€œIt’s dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning.” For example, the FDA received a report about a consumer who purchased a bottle that looked like drinkable water but was actually hand sanitizer. In another report, a retailer informed the agency about a hand sanitizer product that was marketed in a pouch that looks like a children’s snack and had cartoons on it. Meanwhile, the FDA's warning list about dangerous hand sanitizers containing methanol continues to grow as some people are drinking the sanitizers to get an alcohol high.

Others have believed a rumor, circulated online, that drinking the highly potent and toxic alcohol can disinfect the body, protecting them from COVID-19 infection. Earlier this month, the FDA also issued a warning about hand sanitizers contaminated with 1-propanol. Ingesting 1-propanol can cause central nervous system depression, which can be fatal, the agency says.

Symptoms of 1-propanol exposure can include confusion, decreased consciousness, and slowed pulse and breathing. One brand of sanitizer, Harmonic Nature S de RL de MI of Mexico, are labeled to contain ethanol or isopropyl alcohol but have tested positive for 1-propanol contamination. Poison control centers and state health departments have reported an increasing number of adverse events associated with hand sanitizer ingestion, including heart issues, nervous system problems, hospitalizations and deaths, according to the statement.

The FDA encouraged consumers and health care professionals to report issues to the MedWatch Adverse Event Reporting program. The agency is working with manufacturers to recall confusing and dangerous products and is encouraging retailers to remove some products from shelves. The FDA is also updating its list of hand sanitizer products that consumers should avoid.

€œManufacturers should be vigilant about packaging and marketing their hand sanitizers in food or drink packages in an effort to mitigate any potential inadvertent use by consumers,” Hahn said.More than 90% of babies born with heart defects survive into adulthood. As a result, there are now more adults living with congenital heart disease than children. These adults have a chronic, lifelong condition and the European Society of Cardiology (ESC) has produced advice to give the best chance of a normal life.

The guidelines are published online today in European Heart Journal,1 and on the ESC website.2Congenital heart disease refers to any structural defect of the heart and/or great vessels (those directly connected to the heart) present at birth. Congenital heart disease affects all aspects of life, including physical and mental health, socialising, and work. Most patients are unable to exercise at the same level as their peers which, along with the awareness of having a chronic condition, affects mental wellbeing."Having a congenital heart disease, with a need for long-term follow-up and treatment, can also have an impact on social life, limit employment options and make it difficult to get insurance," said Professor Helmut Baumgartner, Chairperson of the guidelines Task Force and head of Adult Congenital and Valvular Heart Disease at the University Hospital of Münster, Germany.

"Guiding and supporting patients in all of these processes is an inherent part of their care."All adults with congenital heart disease should have at least one appointment at a specialist centre to determine how often they need to be seen. Teams at these centres should include specialist nurses, psychologists and social workers given that anxiety and depression are common concerns.Pregnancy is contraindicated in women with certain conditions such high blood pressure in the arteries of the lungs. "Pre-conception counselling is recommended for women and men to discuss the risk of the defect in offspring and the option of foetal screening," said Professor Julie De Backer, Chairperson of the guidelines Task Force and cardiologist and clinical geneticist at Ghent University Hospital, Belgium.Concerning sports, recommendations are provided for each condition.

Professor De Backer said. "All adults with congenital heart disease should be encouraged to exercise, taking into account the nature of the underlying defect and their own abilities."The guidelines state when and how to diagnose complications. This includes proactively monitoring for arrhythmias, cardiac imaging and blood tests to detect problems with heart function.Detailed recommendations are provided on how and when to treat complications.

Arrhythmias are an important cause of sickness and death and the guidelines stress the importance of correct and timely referral to a specialised treatment centre. They also list when particular treatments should be considered such as ablation (a procedure to destroy heart tissue and stop faulty electrical signals) and device implantation.For several defects, there are new recommendations for catheter-based treatment. "Catheter-based treatment should be performed by specialists in adult congenital heart disease working within a multidisciplinary team," said Professor Baumgartner.

Story Source. Materials provided by European Society of Cardiology. Note.

Content may be edited for style and length.One in five patients die within a year after the most common type of heart attack. European Society of Cardiology (ESC) treatment guidelines for non-ST-segment elevation acute coronary syndrome are published online today in European Heart Journal, and on the ESC website.Chest pain is the most common symptom, along with pain radiating to one or both arms, the neck, or jaw. Anyone experiencing these symptoms should call an ambulance immediately.

Complications include potentially deadly heart rhythm disorders (arrhythmias), which are another reason to seek urgent medical help.Treatment is aimed at the underlying cause. The main reason is fatty deposits (atherosclerosis) that become surrounded by a blood clot, narrowing the arteries supplying blood to the heart. In these cases, patients should receive blood thinners and stents to restore blood flow.

For the first time, the guidelines recommend imaging to identify other causes such as a tear in a blood vessel leading to the heart.Regarding diagnosis, there is no distinguishing change on the electrocardiogram (ECG), which may be normal. The key step is measuring a chemical in the blood called troponin. When blood flow to the heart is decreased or blocked, heart cells die, and troponin levels rise.

If levels are normal, the measurement should be repeated one hour later to rule out the diagnosis. If elevated, hospital admission is recommended to further evaluate the severity of the disease and decide the treatment strategy.Given that the main cause is related to atherosclerosis, there is a high risk of recurrence, which can also be deadly. Patients should be prescribed blood thinners and lipid lowering therapies.

"Equally important is a healthy lifestyle including smoking cessation, exercise, and a diet emphasising vegetables, fruits and whole grains while limiting saturated fat and alcohol," said Professor Jean-Philippe Collet, Chairperson of the guidelines Task Force and professor of cardiology, Sorbonne University, Paris, France.Behavioural change and adherence to medication are best achieved when patients are supported by a multidisciplinary team including cardiologists, general practitioners, nurses, dietitians, physiotherapists, psychologists, and pharmacists.The likelihood of triggering another heart attack during sexual activity is low for most patients, and regular exercise decreases this risk. Healthcare providers should ask patients about sexual activity and offer advice and counselling.Annual influenza vaccination is recommended -- especially for patients aged 65 and over -- to prevent further heart attacks and increase longevity."Women should receive equal access to care, a prompt diagnosis, and treatments at the same rate and intensity as men," said Professor Holger Thiele, Chairperson of the guidelines Task Force and medical director, Department of Internal Medicine/Cardiology, Heart Centre Leipzig, Germany. Story Source.

Materials provided by European Society of Cardiology. Note. Content may be edited for style and length.Feeling angry these days?.

New research suggests that a good night of sleep may be just what you need.This program of research comprised an analysis of diaries and lab experiments. The researchers analyzed daily diary entries from 202 college students, who tracked their sleep, daily stressors, and anger over one month. Preliminary results show that individuals reported experiencing more anger on days following less sleep than usual for them.The research team also conducted a lab experiment involving 147 community residents.

Participants were randomly assigned either to maintain their regular sleep schedule or to restrict their sleep at home by about five hours across two nights. Following this manipulation, anger was assessed during exposure to irritating noise.The experiment found that well-slept individuals adapted to noise and reported less anger after two days. In contrast, sleep-restricted individuals exhibited higher and increased anger in response to aversive noise, suggesting that losing sleep undermined emotional adaptation to frustrating circumstance.

Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger. A related experiment in which individuals reported anger following an online competitive game found similar results."The results are important because they provide strong causal evidence that sleep restriction increases anger and increases frustration over time," said Zlatan Krizan, who has a doctorate in personality and social psychology and is a professor of psychology at Iowa State University in Ames, Iowa. "Moreover, the results from the daily diary study suggest such effects translate to everyday life, as young adults reported more anger in the afternoon on days they slept less."The authors noted that the findings highlight the importance of considering specific emotional reactions such as anger and their regulation in the context of sleep disruption.

Story Source. Materials provided by American Academy of Sleep Medicine. Note.

Content may be edited for style and length.Overcoming the nation's opioid epidemic will require clinicians to look beyond opioids, new research from Oregon Health &. Science University suggests.The study reveals that among patients who participated in an in-hospital addiction medicine intervention at OHSU, three-quarters came into the hospital using more than one substance. Overall, participants used fewer substances in the months after working with the hospital-based addictions team than before.The study published in the Journal of Substance Abuse Treatment."We found that polysubstance use is the norm," said lead author Caroline King, M.P.H., a health systems researcher and current M.D./Ph.D.

Student in the OHSU School of Medicine's biomedical engineering program. "This is important because we may need to offer additional support to patients using multiple drugs. If someone with opioid use disorder also uses alcohol or methamphetamines, we miss caring for the whole person by focusing only on their opioid use."About 40% of participants reported they had abstained from using at least one substance at least a month after discharge -- a measure of success that isn't typically tracked in health system record-keeping.Researchers enrolled 486 people seen by an addiction medicine consult service while hospitalized at OHSU Hospital between 2015 and 2018, surveying them early during their stay in the hospital and then again 30 to 90 days after discharge.

advertisement Treatment of opioid use disorder can involve medication such as buprenorphine, or Suboxone, which normalizes brain function by acting on the same target in the brain as prescription opioids or heroin.However, focusing only on the opioid addiction may not adequately address the complexity of each patient."Methamphetamine use in many parts of the U.S., including Oregon, is prominent right now," said senior author Honora Englander, M.D., associate professor of medicine (hospital medicine) in the OHSU School of Medicine. "If people are using stimulants and opioids -- and we only talk about their opioid use -- there are independent harms from stimulant use combined with opioids. People may be using methamphetamines for different reasons than they use opioids."Englander leads the in-hospital addiction service, known as Project IMPACT, or Improving Addiction Care Team.The initiative brings together physicians, social workers, peer-recovery mentors and community addiction providers to address addiction when patients are admitted to the hospital.

Since its inception in 2015, the program has served more than 1,950 people hospitalized at OHSU.The national opioid epidemic spiraled out of control following widespread prescribing of powerful pain medications beginning in the 1990s. Since then, it has often been viewed as a public health crisis afflicting rural, suburban and affluent communities that are largely white.Englander said the new study suggests that a singular focus on opioids may cause clinicians to overlook complexity of issues facing many populations, including people of color, who may also use other substances."Centering on opioids centers on whiteness," Englander said. "Understanding the complexity of people's substance use patterns is really important to honoring their experience and developing systems that support their needs."Researchers say the finding further reinforces earlier research showing that hospitalization is an important time to offer treatment to people with substance use disorder, even if they are not seeking treatment for addiction when they come to the hospital.

Story Source. Materials provided by Oregon Health &. Science University.

Original written by Erik Robinson. Note. Content may be edited for style and length.Researchers from the University of Minnesota, with support from Medtronic, have developed a groundbreaking process for multi-material 3D printing of lifelike models of the heart's aortic valve and the surrounding structures that mimic the exact look and feel of a real patient.These patient-specific organ models, which include 3D-printed soft sensor arrays integrated into the structure, are fabricated using specialized inks and a customized 3D printing process.

Such models can be used in preparation for minimally invasive procedures to improve outcomes in thousands of patients worldwide.The research is published in Science Advances, a peer-reviewed scientific journal published by the American Association for the Advancement of Science (AAAS).The researchers 3D printed what is called the aortic root, the section of the aorta closest to and attached to the heart. The aortic root consists of the aortic valve and the openings for the coronary arteries. The aortic valve has three flaps, called leaflets, surrounded by a fibrous ring.

The model also included part of the left ventricle muscle and the ascending aorta."Our goal with these 3D-printed models is to reduce medical risks and complications by providing patient-specific tools to help doctors understand the exact anatomical structure and mechanical properties of the specific patient's heart," said Michael McAlpine, a University of Minnesota mechanical engineering professor and senior researcher on the study. "Physicians can test and try the valve implants before the actual procedure. The models can also help patients better understand their own anatomy and the procedure itself."This organ model was specifically designed to help doctors prepare for a procedure called a Transcatheter Aortic Valve Replacement (TAVR) in which a new valve is placed inside the patient's native aortic valve.

The procedure is used to treat a condition called aortic stenosis that occurs when the heart's aortic valve narrows and prevents the valve from opening fully, which reduces or blocks blood flow from the heart into the main artery. Aortic stenosis is one of the most common cardiovascular conditions in the elderly and affects about 2.7 million adults over the age of 75 in North America. The TAVR procedure is less invasive than open heart surgery to repair the damaged valve.

advertisement The aortic root models are made by using CT scans of the patient to match the exact shape. They are then 3D printed using specialized silicone-based inks that mechanically match the feel of real heart tissue the researchers obtained from the University of Minnesota's Visible Heart Laboratories. Commercial printers currently on the market can 3D print the shape, but use inks that are often too rigid to match the softness of real heart tissue.On the flip side, the specialized 3D printers at the University of Minnesota were able to mimic both the soft tissue components of the model, as well as the hard calcification on the valve flaps by printing an ink similar to spackling paste used in construction to repair drywall and plaster.Physicians can use the models to determine the size and placement of the valve device during the procedure.

Integrated sensors that are 3D printed within the model give physicians the electronic pressure feedback that can be used to guide and optimize the selection and positioning of the valve within the patient's anatomy.But McAlpine doesn't see this as the end of the road for these 3D-printed models."As our 3D-printing techniques continue to improve and we discover new ways to integrate electronics to mimic organ function, the models themselves may be used as artificial replacement organs," said McAlpine, who holds the Kuhrmeyer Family Chair Professorship in the University of Minnesota Department of Mechanical Engineering. "Someday maybe these 'bionic' organs can be as good as or better than their biological counterparts."In addition to McAlpine, the team included University of Minnesota researchers Ghazaleh Haghiashtiani, co-first author and a recent mechanical engineering Ph.D. Graduate who now works at Seagate.

Kaiyan Qiu, another co-first author and a former mechanical engineering postdoctoral researcher who is now an assistant professor at Washington State University. Jorge D. Zhingre Sanchez, a former biomedical engineering Ph.D.

Student who worked in the University of Minnesota's Visible Heart Laboratories who is now a senior R&D engineer at Medtronic. Zachary J. Fuenning, a mechanical engineering graduate student.

Paul A. Iaizzo, a professor of surgery in the Medical School and founding director of the U of M Visible Heart Laboratories. Priya Nair, senior scientist at Medtronic.

And Sarah E. Ahlberg, director of research &. Technology at Medtronic.This research was funded by Medtronic, the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health, and the Minnesota Discovery, Research, and InnoVation Economy (MnDRIVE) Initiative through the State of Minnesota.

Additional support was provided by University of Minnesota Interdisciplinary Doctoral Fellowship and Doctoral Dissertation Fellowship awarded to Ghazaleh Haghiashtiani..

Buy lasix water pills online

How to buy lasix water pills online cite this article:Singh O P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one of buy lasix water pills online 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 full of stories providing minute details of the buy lasix water pills online 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 buy lasix water pills online 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 buy lasix water pills online getting distress calls from their patients in despair with increased suicidal ideation. This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] The Press Council of India has adopted the guidelines of World Health Organization report on Preventing buy lasix water pills online 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 buy lasix water pills online full of speculations about the person's mental condition and illness and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking buy lasix water pills online for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident.

Many psychiatrists and mental health buy lasix water pills online professionals were called by media houses to comment on the episode. Many psychiatrists were quoted, or “misquoted,” or “quoted out of context,” commenting on the 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 buy lasix water pills online 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” buy lasix water pills online can be a double-edged sword, and we should know about the rules of engagements and boundaries of interactions.

Methods and principles of interaction with media should form a part of our training curriculum. Many professional societies have guidelines and resource books for interacting with media, and psychiatrists should familiarize themselves with buy lasix water pills online 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 buy lasix water pills online 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 buy lasix water pills online Township, Kolkata - 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 buy lasix with free samples. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity suicide is one buy lasix with free samples 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, buy lasix with free samples 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 buy lasix with free samples process, reputations of many people associated with the actor were besmirched and their private and personal details were freely and blatantly broadcast and discussed on electronic, print, and 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 buy lasix with free samples patients in despair with increased suicidal ideation.

This has become a major area of concern for the psychiatry community.The Indian Psychiatric Society has been consistently trying to engage with media to promote ethical reporting of suicide. Section 24 (1) of Mental Health Care Act, 2017, forbids publication of photograph of mentally ill person without his consent.[1] The buy lasix with free samples 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 buy lasix with free samples and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more buy lasix with free samples 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 buy lasix with free samples media 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 psychiatry and are detrimental buy lasix with free samples 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” can be a double-edged sword, and we should know about the rules of engagements and buy lasix with free samples boundaries of interactions. Methods and principles of interaction with media should form a part of our training curriculum.

Many professional buy lasix with free samples societies have guidelines and resource books for interacting with media, and psychiatrists should familiarize themselves with these documents. The Press Council guideline is likely to prompt reporters to seek psychiatrists for their expert opinion. 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 buy lasix with free samples limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal buy lasix with free samples 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. Electroconvulsive therapy.

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

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