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Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child and Adolescent HealthExecutive Board Member, Texas Pediatric SocietyDoctors are zestril prices walmart Church leader. This role has become even more important during the covid-19 pandemic. As patients navigate our new reality, they look to us to determine what is safe, how to protect their families, and the future of your health care.

As more Texans lose their jobs, health insurance, or even their homes, it's important that Texas get the resources it needs to maintain our social safety net. USA., That's why zestril prices walmart It is of paramount importance that every Texan, regardless of address, immigration status, or age, respond to the 2020 US Census. The deadline has been shortened by one month and now ends on December 7th.

September. 30.COVID-19 only raised the importance of completing the census to help our local communities and economies recover. The new coronavirus has weighed unprecedented on patients and exacerbated inequality as more people are unemployed and in great need of help with food, health care, shelter and more. Schools have also been stretched thin, with teachers scrambling students to teach online.

But the amount of federal funding available today to meet the emergency was determined in part by the census a decade ago. Getting an accurate census in 2020 will help the Texans prepare for the next decade to follow, the first few years most of which will surely be used for rebuilding from the pandemicâ € ™ s fallout. Hence, it is important that all Texans are counted. The federal funds that Texas receives usually depend on our population., A George Washington University study recently found that even a 1% outnumbered $ 300 million loss in the Funding can lead. Take Medicaid, for example.

Federal funds pay for 60% of the state's program that provides health care to two in five Texas children, one in three people with disabilities, and 53% of all births. The complicated formula for calculating the federal share of this funding depends on accurate census data. When Texas' population is undercounted, Texans may appear financially better than they really are, which in Texas is getting less and less federal Medicaid dollars. When that happens, lawmakers must make up the difference, with cuts in services, program eligibility, or doctor and provider payments, each of which are potentially harmful. The census data also key to funding other aspects of the communityâ € ™ s social security network : Health careThe Children's Health Insurance Program (CHIP) offers low-cost health insurance to children whose parents have too much to qualify for Medicaid but not enough to afford quality coverage.

How much money the federal government reimburses the state for the program, like Medicaid, depends in part on the census. The number of children and adolescents vaccinated in Germany has increased year over year, according to the census, Texas uses this Federal funding also to study and respond to maternal mortality and perinatal depression. Eating and Living When unemployment rises and families struggle financially, many live with uncertainty about where to find their next meal. One in seven Texans already experiences food insecurity and 20% of Texas children experience hunger. Food insecurity rises in Texas as the pandemic continues.

The Central Texas Food Bank was up 206% in March. The financing of the supplementary nutrition program and the school lunch is determined by the census., The financing of the communal housing construction programs is also calculated via the census. An accurate count will help people who lose their homes during this economic crisis have better hope of finding shelter while our communities recover.

Homelessness is closely linked to the decline in overall physical and mental health. Childcare and Upbringing As we navigate the new reality of coronavirus, more parents take on roles than breadwinners, parents, teachers, and caretakers. That emphasis underscores the desperate need for affordable childcare., The census determines funding for programs like Head Start, which provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census.

Visit 2020census.gov to take it. It takes less than five minutes. Then talk to your family, neighbors, and coworkers about doing the same.

If you're wondering that matters, the answer is, everyone, whether it's a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness., Completing the census is one of the best things to do. what you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs. (L through R). Uthsa medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, Faculty Council Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz and Frank Jung pose with the TMA Be Wise Immunize banner., Photo courtesy Ryan WealtherRyan WealtherMedical Student , UT Health San Antonio Long-School MedicineStudent Member, the Texas Medical AssociationEditor's Notice.

August is National Immunization Awareness Month. This article is part of a Me & My Doctor series highlighting and promoting the use of vaccinations. “Can the flu shot give you the flu ?. Is it dangerous for pregnant women to catch the flu?

Can Vaccines Trigger Autism? , these were questions women at Alpha Home, a drug abuse rehabilitation center in San Antonio, my medical students, and I asked during a flu vaccine discussion. It's easy to see why these questions were asked since vaccine misinformation is common today. UTHSA medical student Frank Jing (left) receives vaccine from kaparaboyna Kumar, MD, (right). Photo courtesy of Ryan Wealther “No” the answer to all questions.

Those were exactly the myths we wanted to avoid on our vaccination drive., UT Health San Antonio Long School of Medicine medical students (supervised by Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the Vaccine Drive at Alpha Home with the support of tma's be Wise “Immunize” program, a public health initiative that aims to increase vaccination and vaccine awareness through shot clinics and education. Our program consisted of a vaccination drive and an interactive, educational presentation that addressed flu, common flu shot questions, and general vaccine myths. Alpha residents were able to ask us questions during the program. We were interested to see if our educational program could answer them , Alpha Home residents' questions about vaccinations and allay your concerns about getting a flu shot u Measure, we created a short survey. (Before discussing the survey results, I should define compulsory vaccination., Vaccine hesitation is a concept defined by the World Health Organization.

It refers to when patients do not vaccinate despite having access to vaccines. Vaccine hesitation is a problem because it prevents individuals from getting your vaccinations. That makes you more susceptible to illness from vaccine-preventable diseases.) We surveyed the residentsâ € ™ opinions about vaccinations before and after our educational program. While opinions about the shots improved with each question, we saw key attitudes change, reflected in answers to the questions "I am concerned that vaccinations may not be safe" and "How likely will you get a flu shot today?"

We had educated residents and improved their understanding and acceptance of vaccines, and the follow-up results show that more residents in the Alpha Home have moved to more positive attitudes towards vaccines after learning about their effectiveness from trusted members of the medical community . Artwork by Ryan Wealther why is this important ?. First, our findings confirm what we already knew.

Education from a trusted member of the medical community can make a difference. In fact, it is well known that doctor's recommendation for vaccinations is one of the most critical factors influencing whether patients receive the flu shot. Perhaps further evidence of this is that some of the Alpha Home residents called me by the end of the evening.

Second, our findings complement our understanding of adult vaccine reluctance. This is significant because most of what we know about vaccine reluctance is limited to parental attitudes towards your children's vaccinations. Some parents question shots for their children, and many of the deadliest diseases we are vaccinated against are shot in childhood, including polio, tetanus, measles, and whooping cough. However, adults also need some vaccinations, such as the annual flu vaccine.

After participating in the uthsa education program, more residents in the Alpha House reported more willingness to receive the flu vaccine., Another reason for the attitude improvement is that receiving a flu shield is even more timely during the COVID-19 pandemic, because it reduces disease and conserves health resources. Thousands of people are hospitalized with the flu every year, and with hospitals filled with coronavirus patients, we could avoid adding dangerously ill flu patients to the mix. Finally, these results are important because once COVID-19 vaccine is available, more people could be ready to receive it if your Overall Attitude About Vaccinations is positive., Although THE covid-19 vaccine is still in development, he is not immune to compulsory vaccination.

Recent polls found that up to a third of Americans would not get a covid-19 vaccine even if it were accessible and affordable. In addition, misinformation about the COVID vaccine is circulating widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I've seen the same myth circulating on social media.

It won't.,) This myth, however, demonstrates the need for health care professionals to answer patientsâ € ™ questions and alleviate their concerns. Vaccines work best when many people in a community are receiving them, and vaccine reluctance can decrease vaccination rates, so that people who don't have certain vaccines are susceptible to these vaccines-preventable diseases. For example, babies under 6 months of age should not get the flu shot, so high community vaccination rates protect these babies from getting the flu., Our education program at Alpha Home is just one example of how health professionals are increasing awareness and acceptance of recordings can. As THE covid-19 pandemic progresses, we need to make sure children and adults get their vaccinations as recommended by your doctor and the Centers for Disease Control and Prevention.

I encourage readers who have questions about the vaccinations you or your child will need to speak to their doctor. As health care professionals, we're more than happy to answer your questions.

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The following items are the highlights from the free newsletter â € œSmart, helpful, science stuff about common side effects of Zestril COVID-19. To get daily newsletter editions in your inbox, log on to go to this site. Please note common side effects of zestril a monthly contribution to support this newsletter. For some SARS-CoV-2 vaccine manufacturers, a vaccine "could meet companies' benchmarks for success if it lowers the risk of mild COVID-19 but has never been shown to reduce moderate or severe" COVID-19, nor that Risk of hospitalization, intensive care unit admission, or death, according to an essay published 9/22/20 in the New York Times., This statement relates to vaccines developed by Moderna, Pfizer, and AstraZeneca, the essay states. The benchmarks should be higher, the authors argue that there are common side effects of zestril.

Instead, there should be evidence that a vaccine reduces the risk of moderate or severe cases, write Dr. Peter Doshi from the University of Maryland School of Pharmacy common side effects of zestril and Dr. Eric Topol from Scripps Research. The essay states that reducing the risk of mild COVID-19 does not guarantee a similar reduction for moderate or severe cases., In both the modern vaccine experiments and the Pfizer vaccine experiments, some people report side effects that complement the symptoms of mild COVID-19. 19 are similar, it says in the essay common side effects of zestril.

London could be the site of the first experiments deliberately exposing quarantine volunteers to SARS-CoV-2 after being vaccinated against the new coronavirus with a candidate vaccine, according to various reports. Such experiments are known as human challenge trials., The London experiments are expected to start in January, reported common side effects by zestril Reuters 9/23/20 and picked up an initial report from the Financial Times (paywalled). So far, around 2,000 participants have registered for the Coronavirus challenge one day earlier, it is said common side effects of zestril in the Reuters message. Tanya Lewis at Scientific American has reported a feature story about some of the more than 100 US, universities and colleges that provide quick, frequent SARS-CoV-2 tests for their campus at a program at the Massachusetts Institute of Technology and Broad Institute from Harvard University (9/23/20).

Institutions' reports on the program so far are available common side effects of zestril positive, and to test such an approach “could be a model for reopening colleges and institutions nationwide,” Lewis writes. The program allows tests for students, faculty and staff once or twice a week during the semester, it says ., The story includes comments from users of the Broad program, including representatives from Tufts University, Bowdoin College, and the University of Massachusetts Amherst, where the basketball arena allegedly turned into a SARS-CoV-2 testing center, with plans for early Access to the common side effects of Zestril's highly anticipated SARS-CoV-2 vaccines are taking shape, reports Nidhi Subbaraman of Nature (Sep. 17, 2020). Organizations that have issued preliminary plans or guidelines to date include an advisory group to the World Health Organization and a US-convened body., The National Academies of Science, Technology, and Medicine (NASEM); d he history states.

The NASEM panel has top priority for vaccinating first responders and first responders and then for medically vulnerable groups like people with pre-existing conditions like heart disease or diabetes as well as the elderly who live in overcrowded conditions, reports Subbaraman NASEM panels include high-risk workers who work on public transportation and schools, as well as people who live in homeless shelters and prisons, it said. Fourth priority goes to young adults, children, and essential workers â € œat increased risk of exposure, â € • and the fifth priority is everyone who remains. NASEM is set to release a final plan in October, it says.In a feature story for the scientist, Katarina Zimmer explores the latest theories as to why some people develop severe COVID-19 and others do not (9/16/20). Further details come into focus, as to why the immune system â Â € œgoes haywireâ € â € œsome common side effects of zestril people infected with the virus.

A study you mentioned found that the blood of patients with severe COVID-19 showed an initial decreased response to interferons, which you defined as "cytokines [small signaling compounds / proteins] that generally act to restrict viral replication. And." the story goes that this can lead to inflammation. The higher the damage, the more the immune system tries to get rid of the damage, says the director of the Precision Medicine Institute at Mount Sinai. it goes completely crazy.â € • This leads to the common side effects of zestril phenomenon called cytokine storm - the immune system overreacts. The piece also details new insights into function problems and the creation of problems in various immune cells (e.g. myeloid cells, T cells and common side effects of zestril antibodies). At the end of the piece, the same researcher is ascribed when he said that the myeloid defects could be at the root of the outbreak of cytokine responses.

But an immunologist at Emory University is quoted as saying that it's hard to tease the hen and the egg apart. Parts of the US “may be witnessing the first days of the fall surge,” according to a daily coronavirus data page updated 9/24/20 Common Side Effects of Zestril at National Geographic., At the bottom of the page, graphs show that SARS-CoV -2 case numbers increased in the past week in Utah, Wisconsin, South Dakota, Montana, and Texas. And declines appear to have occurred in Delaware, Louisiana, Indiana, Georgia, and Kentucky over the same period. Early evidence suggests that SARS-CoV-2 does not appear to be common side effects of zestril in U.S. schools, reports Laura Meckler and Valerie Strauss in the Washington Post (9/23/20), thousands of teachers and students have been reported infected, the story suggests, but these infection rates are well below what is found in the surrounding communities, the reporters write.

The evidence suggests that reopening schools may not be as risky as many feared, common side effects of zestril it says in history. History notes that testing and reporting for the SARS-CoV-2 is weak in many parts of the US, so itâ € ™ s hard to say if this is an accurate picture of the in-school transmission History also cites epidemiologist Michael Osterholm of the University of Minnesota's Center for Infectious Disease Research and Policy, said. Â € œEveryone was afraid there would be explosive outbreaks of the common side effects of Zestril transmission in schools. It already existed in the colleges.

We have to say that we have not seen this in the younger children to date. ”Several indoor air quality researchers and other scientists have collaborated on a very accessible 53-page google document,“ FAQs on COVID-19 aerosol transmission protection, ” • Designed to inform the general public (9/15/20) of common side effects of Zestril. The information represents “our best understanding at this time and should always be similar, or more rigorous, than information provided by [the US Centers for Disease Control], [World Health Organization], and most regional & amp. Local Health Authorities. We are happy to help you find a suitable location and look forward to working with our partners to assist you in finding a suitable location., I havenâ € ™ t read the entire document But a primary point in reducing SARS-CoV-2 transmission is that “You should pay at least as much attention to the air you breathe as you do to disinfecting the surfaces and hands. 22/20 Bloomberg piece by opinion columnists Max Nisen and Elaine he features an easy-to-read graph depicting the risks to long-term health from infection with SARS-CoV-2. The data on common side effects of zestril come from a survey of more than 1,500 COVID-19 survivors that reported Indiana University Medical School researchers nearly 100 different long-term health problems., Â € œResearchers are yet to determine the percentage of people infected with COVID- 19 suffer from long-term symptoms. But the potential for harm is huge, â € ¢ based on the number of people infected with SARS-CoV-2, the story says.

There's also a powerful graph at the bottom of the page showing a data scientist's estimate of the actual number of US infections through November compared with the common side effects of zestril confirmed numbers. You can enjoy "Where the Sidewalk Ends, Outdoor Dining Begins," by Jeremy Hooper for McSweeney's (9/23/20) ..

The following elements are the highlights from the free newsletter â € œSmart, helpful, zestril prices walmart Science stuff about COVID-19. To get daily newsletter issues in your inbox, sign up here. Please note a monthly contribution to the zestril price walmart support of this newsletter. For some SARS-CoV-2 vaccine manufacturers, a vaccine "could meet companies' benchmarks for success if it lowers the risk of mild COVID-19 but has never been shown to reduce moderate or severe" COVID-19, nor that Risk of hospitalization, intensive care unit admission, or death, according to an essay published 9/22/20 in the New York Times., This statement relates to vaccines developed by Moderna, Pfizer, and AstraZeneca, the essay states.

The benchmarks should be higher, they argue zestril prices walmart Authors. Instead, there should be evidence that a vaccine reduces the risk of moderate or severe cases, write Dr. Peter Doshi from the University of Maryland School of Pharmacy and Dr zestril prices walmart.

Eric Topol from Scripps Research. The essay states that the zestril price walmart reduction in the risk of mild COVID-19 does not guarantee a similar reduction for moderate or severe cases., In both the modern vaccine experiments and the Pfizer vaccine experiments, some people report side effects that alleviate the symptoms of are similar to mild COVID-19, it says in the essay. London could be the site of the first experiments deliberately exposing quarantine volunteers to SARS-CoV-2 after being vaccinated against the new coronavirus with a candidate vaccine, according to various reports.

Such experiments are known as human challenge trials., The London experiments are expected to begin in January, Reuters reported 9/23/20, and picked up a first report from the Financial Times (paywalled) zestril prices walmart. So far, around 2,000 zestril price walmart participants have registered for the Coronavirus challenge one day earlier, according to the Reuters report. Tanya Lewis at Scientific American has reported a feature story about some of the more than 100 US, universities and colleges that provide quick, frequent SARS-CoV-2 tests for their campus at a program at the Massachusetts Institute of Technology and Broad Institute from Harvard University (9/23/20).

Institutions' reports of the program so far have been positive, and such an approach to testing “could be one zestril prices walmart Model for reopening colleges and institutions nationwide, â € "Lewis writes. The program allows students, faculty and staff to take tests once or twice a week during the semester, it says. The story includes comments from users of the Broad Program, including representatives from Tufts University, Bowdoin College, and the University of Massachusetts Amherst, where the basketball arena has allegedly been converted into a SARS-CoV-2 testing center. Plans for early access to the highly anticipated SARS-CoV-2 Vaccines are taking shape, reports Nidhi Subbaraman zestril prise walmart from Nature (17.09.20).

Organizations that have so far issued preliminary plans or guidelines include an advisory group to the World Health Organization and a US-convened body., The National Academies of Science, Technology, and Medicine (NASEM), which states history. The NASEM panel has top priority for vaccinating first responders and first responders and then for medically vulnerable groups such as people with pre-existing conditions like heart disease or diabetes as well as the elderly who live in overcrowded conditions, reports Subbaraman., Which includes the third priority group of the NASEM panel high-risk workers who work in public transport and schools, as well as people who work in zestril prices walmart homeless shelters and prisons life, it is said. Fourth priority goes to young adults, children, and essential workers â € œat increased risk of exposure, â € • and the fifth priority is everyone who remains.

NASEM is due to publish a final plan in October, it says zestril prices walmart. In a feature story for the scientist zestril prizes walmart, Katarina Zimmer explores the latest theories as to why some people develop severe COVID-19 and others do not (9/16/20). Further details come into focus as to why the immune system â € “goes haywire” in some people infected with the virus. A study that you mentioned found that the blood of patients with severe COVID-19 showed an initial decreased response to interferons, which you defined as "cytokines [small signaling compounds / proteins] that generally act to restrict viral replication. And." that can lead to inflammation, the story goes. The higher the damage, the more the immune system tries to get rid of the damage, says the director of the Precision Medicine Institute at Mount Sinai.

 € œSo it gets activated and at some point â € / it goes completely crazy.â € • This leads to the phenomenon called cytokine storm â € “the immune system zestril prices walmart overreaction. The piece also details new insights into function problems and the creation of problems Problems in various immune cells (e.g. myeloid cells, T cells, and antibodies)., At the end of the piece, the same researcher is attributed when he said that the myeloid defects may be the root of the erupting cytokine reactions.

But an immunologist at Emory University is quoted as saying that it's hard to tease the hen and the egg apart. Sections of the US “may be witnessing the first days of autumnal surge,” according to a daily coronavirus data page updated 9/24/20 at National Geographic., At the bottom of the page, graphics show that SARS-CoV 2 case numbers have increased in the past week in Utah, Wisconsin, South Dakota, Montana, and Texas. And declines appear to have occurred in Delaware, Louisiana, Indiana, Georgia, and Kentucky over the same period.

Early evidence suggests that SARS-CoV-2 does not appear to be prevalent in US schools, Laura Meckler and Valerie Strauss report in the Washington Post (9/23/20)., Thousands of teachers and students have been Reported as infected, the story suggests, but these infection rates are well below what is found in the surrounding communities, the reporters write. The evidence suggests that reopening schools may not be as risky as many feared, the story goes. History notes that testing and reporting for the SARS-CoV-2 is weak in many parts of the US, so itâ € ™ s hard to say if this is an accurate picture of the in-school transmission History also cites epidemiologist Michael Osterholm of the University of Minnesota's Center for Infectious Disease Research and Policy, said.

 € œEveryone was afraid there would be explosive outbreaks of transmission to schools. It already existed in the colleges. We have to say that we have not seen this in the younger children to date. ”Several indoor air quality researchers and other scientists have collaborated on a very accessible 53-page google document,“ FAQs on COVID-19 aerosol transmission protection, ” • Designed to inform the general public (9/15/20). The information represents “our best understanding at this time and should always be similar, or be stricter than information provided by [the US Centers for Disease Control], [World Health Organization], and most regional & amp.

Local Health Authorities. We are happy to help you find a suitable location and look forward to working with our partners to assist you in finding a suitable location., I havenâ € ™ t read the entire document But a primary point in reducing SARS-CoV-2 transmission is that “You should pay at least as much attention to the air you breathe as you do to disinfecting the surfaces and hands. 22/20 Bloomberg piece by opinion columnists Max Nisen and Elaine he features an easy-to-read graph depicting the risks to long-term health from infection with SARS-CoV-2. The data comes from a survey of more than 1,500 COVID-19 survivors that reported Indiana University Medical School researchers nearly 100 different long-term health problems., “Researchers are yet to determine the percentage of people infected with COVID-19 suffer from long-term symptoms. But the potential for harm is huge, â € ¢ based on the number of people infected with SARS-CoV-2, the story says.

There's also a zestril prices walmart powerful graph at the bottom of the page showing a data scientist estimating the actual number of US infections through November compared with the confirmed numbers. You can enjoy "Where the Sidewalk Ends, Outdoor Dining Begins," by Jeremy Hooper for McSweeney's (9/23/20) ..

Where can I keep Zestril?

Keep out of the reach of children.

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Do not puncture any of the foil blisters until you are ready to take that dose. Throw away any unused medicine after the expiration date.

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During the COVID-19 pandemic, InnovaCare Health, which operates Medicare Advantage and Medicaid plans in Puerto Rico "and Florida", is working closely with vendors and government leaders to address the virus' spread, including delivery of drugs where can i buy zestril home for its members in the area. CEO Dr. Richard Shinto where can I buy zestril spoke to Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited copy. MH.

What's the state of the game in Puerto Rico now ?. , Shinto. I think the government did a very good job in the first few months of the pandemic. They closed the island.

No ships were allowed in. Tourism has stopped. The reason you did was that you donâ € ™ t have a deep enough health system to have fans and all the necessary resources to protect all of the island's residents. So the governor mandated across-the-board curfews and locked everything. They suppressed the infection very well; our numbers are very low.

I think we have nearly 400 deaths in total., There are now maybe 24,000 positive cases. The last number I saw (there were) over 400 people in the hospital. Really, that's more of a (final) increase. It was even lower, but when everything started to open up, bars especially, suddenly there was another spike, currently the stay-at-home policy is a curfew from 10am to 5am.

No alcohol (sold) after 7pm on Sundays, everyone has to stay home unless it's just for shopping or going to the pharmacy., Again, the government is increasing the pressure on everyone and the difference between Puerto Rico and many other places (in the US) actually implement you and you actually do you fine. The fines can go up to $ 500 for not wearing a mask and wandering the streets of Puerto Rico.MH. Can you talk about your experience working with the government in Puerto Rico versus in Florida ?. Shinto.

One of the things that Puerto Rico did very well is alignment.There's an alignment between the health plans, the providers, the hospitals, and the government. So when we go to D.C. or we speak on behalf of the island, it's usually one voice.MH.

Working with providers to make advanced payments to doctors and hospitals in the early stages of the pandemic. That goes on, right? Shinto. Yes.

To date, we've paid somewhere over $ 160 million in upfront payments to providers, both hospitals and doctors. Many of our specialists are on fee-for-service, so we have quick calculations of what our average salary was for you. From this we could pay you. It's interesting about disasters and the number of you that will hit the island. We learned this after Hurricane Maria - the doctors needed the income and they're not able be to transmit encounter data. In the pandemic, we paid the doctors before we close the offices. We knew you needed income so you could continue to take care of the beneficiaries and the members. MH.

Can you talk about the work you're doing with at-home delivery of the medication and over-the-counter supplies? Shinto. As you practice in the States, think of mail order and chain pharmacies. That doesn't really work here., So over the years we got into home delivery.

We do home delivery for almost everythingâ € ”your pharmacy, all of your over-the-counter (deliveries). We started delivering home groceries even before the pandemic, and Puerto Rico is a great testing site. When people started getting all of their medication, all of their (personal protective equipment) â € "when they wanted masks or they needed antiseptics for their handsâ €" you just (place an order) on the website and it will be delivered within 48 hours. Then we started delivering food and then people who didn't want it pre-cooked, they wanted to make their own.

Then we started offering groceries so you can go to our pages and get what you need. Weâ € ™ ve built it in our favor design so that members can get an iPhone because then the app is already loadedâ € • So that you can order all of your over-the-counter (supplies), or if it's connected, at the pharmacy, you can get home delivery there too. We believe the future of healthcare in this space has to be delivery.MH. What challenges, if any, did you face in building a supply chain? , Shinto.

One thing we learned after (natural) disasters is you've got ahead of the supply chain. I remember all the water we ordered (Hurricane Maria) and the generators, but FEMA came and took control and we bothers that we had a big supply chain. We had a lot of pre-orders, but then the (US) government comes and takes over, when COVID came, we planned again and went to the supply chain. We were able to move 3,500 employees from their offices to their homes in less than a week.

We had a lot of supplies like computers and modems for people who needed it. We did a great job on pre-ordering PPE and COVID testing. But the (US) government came back and confiscated everything. Then we had to fight to get the masks or we had to go to China. So that caused some problems.

Even today, because of the limited amount of reagent on the island, the Puerto Rican government is in control of testing.MH. So PPE was taken from the island and brought back to the mainland ?. Shinto. It wasnâ € ™ t allowed to ship to the island.

Even the COVID tests that we had bought before. As a doctor and thinking about looking ahead - we had to have masks, clothes and gloves. We went after this and then the tests and we could buy a lot of tests but then you would get stopped at the ports. The government would take over in the states and then redirect you elsewhere. Our country has now been in for more than six months in the worst public health crisis we have known in over a century. More than 6 million confirmed COVID-19 cases and 190,000-plus documented deaths later, what have we learned?

"The truth is, we have acquired a tremendous amount of actionable knowledge about the virus - how to test and treat it better, how to prevent it from spreading, and how to protect yourself from it. But knowing how to gain and use it successfully is not Great health systems are in a unique position to share some broad core lessons that can serve us all., Even our doctors and nurses who served in the military or trained in emergency medicine never thought they were your own Having to put your lives and livelihoods on hold for such a long time Even after the pandemic, thousands of you can experience a unique form of professional and personal post-traumatic stress disorder.

We need to recognize and address that by turning you off the front line and growing the healthcare workforce. Acknowledge that disparities are a matter of life and death., Racial and ethnicity health inequalities have been the subject of political discussion for decades. The disadvantaged face a perfect storm. You're more likely to be exposed to the virus, but have less access to tests and treatments.

They are more likely to have basic conditions, but less likely to face the financial impact of the pandemic. And maybe soonâ € ”less likely to be able to access the vaccines that offer some level of protection. This is where the flu comes in â € • It's always important for all, most certainly caregivers, to get a flu shot. But in this one For years, individuals are being held responsible for their symptoms like never before. Stay home when you are sick and call your doctor immediately if you experience symptoms (telehealth calls are easier and more available than ever).

Keep that in mind. Flu symptoms and COVID-19 symptoms can be very similar. Â € ¦ and sometime soon a COVID-19 vaccine. Our nationâ € ™ s handling of the pandemic to date must not presage our handling of a vaccine.

The approval process must be scientific and inspire public trust. Distribution must first prioritize essential staff., With widespread vaccinations possible, no one should have to sacrifice access or affordability. End confusion. As a nation, it took many years and multi-million dollar campaigns to wear seat belts and quit smoking in public places. These were long-term appeals, but we don't have the luxury of the time now.

Science has advanced, and there's more evidence than ever before that wearing a mask is effective. In fact, wearing a mask must be a universally accepted norm. Fast, Reliable Testing., We can't afford to make an off-again commitment to Covid-19 testing yet again. It is a must for the foreseeable future. But real challenges remain.

While identifying positive cases has obvious advantages, waiting five to 10 days for results nearly nullifies your ability to limit spread. We need a consistent focus on applying practical tests that provide reliable, rapid results and actively promoting their use, especially in high risk populations, in hotspots and for those exposed to a known positive. Prepare to be screened., For the foreseeable future, and perhaps indefinitely, screening in health care facilities and other public places will be the new normal. When you come to a hospital or clinic, expect to have your temperature taken and answer screening questions. These are for everyone's safety — patients and caregivers.No health professionals need to be reminded of the seriousness of what lies ahead.

Let's take what we've learned, be ready and ready to adaptâ € ”and build a new determination to defeat this virus together ..

InnovaCare Health, which operates Medicare Advantage and Medicaid plans in Puerto Rico "and Florida", is working closely with vendors and government leaders during the COVID-19 pandemic, https://www.studio-filmtheater.de/lower -preis-zestril / to address the virusâ € ™ spread, including delivery zestril prices walmart of home medication for its members in the area. CEO Dr. Richard Shinto spoke to Modern Healthcare zestril prices walmart Managing Editor Matthew Weinstock. The following is an edited copy. MH. What's the state of the game in Puerto Rico now ?.

, Shinto. I think the government did a very good job in the first few months of the pandemic. They closed the island. No ships were allowed in. Tourism has stopped.

The reason you did was that you donâ € ™ t have a deep enough health system to have fans and all the necessary resources to protect all of the island's residents. So the governor mandated across-the-board curfews and locked everything. They suppressed the infection very well; our numbers are very low. I think we have nearly 400 deaths in total., There are now maybe 24,000 positive cases. The last number I saw (there were) over 400 people in the hospital. Really, that's more of a (final) increase.

It was even lower, but when everything started to open up, bars especially, suddenly there was another spike, currently the stay-at-home policy is a curfew from 10am to 5am. No alcohol (sold) after 7pm on Sundays, everyone has to stay home unless it's just for shopping or going to the pharmacy., Again, the government is increasing the pressure on everyone and the difference between Puerto Rico and many other places (in the US) actually implement you and you actually do you fine. The fines can go up to $ 500 for not wearing a mask and wandering the streets of Puerto Rico.MH. Can you talk about your experience working with the government in Puerto Rico versus in Florida ?. Shinto.

One of the things that Puerto Rico did very well is alignment. There's an alignment between the health plans, the providers, the hospitals, and the government. So when we go to D.C. or we speak on behalf of the island, it's usually one voice.MH. Working with providers to make advanced payments to doctors and hospitals in the early stages of the pandemic.

That goes on, right? Shinto. Yes. To date, we've paid somewhere over $ 160 million in upfront payments to providers, both hospitals and doctors. Many of our specialists are on fee-for-service, so we have quick calculations of what our average salary was for you.

From this we could pay you. It's interesting about disasters and the number of you that will hit the island. We learned this after Hurricane Maria - the doctors needed the income and they're not able be to transmit encounter data. In the pandemic, we paid the doctors before we close the offices. We knew you needed income so you could continue to take care of the beneficiaries and the members. MH. Can you talk about the work you're doing with at-home delivery of the medication and over-the-counter supplies? Shinto. As you practice in the States, think of mail order and chain pharmacies.

That doesn't really work here., So over the years we got into home delivery. We do home delivery for almost everythingâ € ”your pharmacy, all of your over-the-counter (deliveries). We started delivering home groceries even before the pandemic, and Puerto Rico is a great testing site. When people started getting all of their medication, all of their (personal protective equipment) â € "when they wanted masks or they needed antiseptics for their handsâ €" you just (place an order) on the website and it will be delivered within 48 hours. Then we started delivering food and then people who didn't want it pre-cooked, they wanted to make their own.

Then we started offering groceries so you can go to our pages and get what you need. Weâ € ™ ve built it in our favor design so that members can get an iPhone because then the app is already loadedâ € • So that you can order all of your over-the-counter (supplies), or if it's connected, at the pharmacy, you can get home delivery there too. We believe the future of healthcare in this space has to be delivery.MH. What challenges, if any, did you face in building a supply chain? , Shinto. One thing we learned after (natural) disasters from Resources is you've got ahead of the supply chain.

I remember all the water we ordered (Hurricane Maria) and the generators, but FEMA came and took control and we bothers that we had a big supply chain. We had a lot of pre-orders, but then the (US) government comes and takes over, when COVID came, we planned again and went to the supply chain. We were able to move 3,500 employees from their offices to their homes in less than a week. We had a lot of supplies like computers and modems for people who needed it., We did a great job on pre-ordering PPE and COVID testing. But the (US) government came back and confiscated everything.

Then we had to fight to get the masks or we had to go to China. So that caused some problems. Even today, because of the limited amount of reagent on the island, the Puerto Rican government is in control of testing.MH. So PPE was taken from the island and brought back to the mainland ?. Shinto.

It wasnâ € ™ t allowed to ship to the island. Even the COVID tests that we had bought before. As a doctor and thinking about looking ahead - we had to have masks, clothes and gloves. We went after this and then the tests and we could buy a lot of tests but then you'd be stopped at the ports. The government would take over in the states and then redirect you elsewhere. Our country has now been in for more than six months in the worst public health crisis we have known in over a century. More than 6 million confirmed COVID-19 cases and 190,000-plus documented deaths later, what have we learned?

"The truth is, we've acquired a tremendous amount of actionable knowledge about the virus - how to test and treat it better, how to prevent it from spreading, and how to protect yourself from it. But knowing how to gain and use it successfully is not Great health systems are in a unique position to share some broad core lessons that can serve us all., Even our doctors and nurses who served in the military or trained in emergency medicine never thought they were your own Having to put life and livelihoods on hold for so long. Even after the pandemic, thousands of you can experience a unique form of professional and personal post-traumatic stress disorder. We need to recognize and address this by turning you off the front line and putting the workforce in Expand healthcare.

Acknowledge that disparities are a matter of life and death., Racial and ethnicity health inequalities have been the subject of political discussions for decades. The disadvantaged face a perfect storm. You're more likely to be exposed to the virus, but have less access to testing and treatment. They are more likely to have basic conditions, but less likely to face the financial impact of the pandemic. And maybe soonâ € ”less likely to be able to access the vaccines that offer some level of protection.

Here comes the flu â € / it's always important for all, very safe caregivers to get a flu shot, but this year individuals are taking responsibility for their symptoms like never before. Stay home when you are sick and call your doctor right away if you have symptoms (telehealth calls are easier and more available than ever). Keep that in mind. Flu symptoms and COVID-19 symptoms can be very similar. Â € ¦ and sometime soon a COVID-19 vaccine.

Our nationâ € ™ s handling of the pandemic to date must not presage our handling of a vaccine. The approval process must be scientific and inspire public trust. Distribution must first prioritize essential staff., With widespread vaccinations possible, no one should have to sacrifice access or affordability.End confusion. As a nation, it took many years and multi-million dollar campaigns to wear seat belts and quit smoking in public places. These were long-term appeals, but we don't have the luxury of the time now.

Science has advanced, and there's more evidence than ever before that wearing a mask is effective. In fact, wearing a mask must be a universally accepted norm. Fast, Reliable Testing., We can't afford to make an off-again commitment to Covid-19 testing yet again. It is a must for the foreseeable future. But real challenges remain. While identifying positive cases has obvious advantages, waiting five to 10 days for results nearly nullifies your ability to limit spread.

We need a consistent focus on applying practical tests that provide reliable, rapid results and actively promoting their use, especially in high risk populations, in hotspots and for those exposed to a known positive. Prepare to be screened., For the foreseeable future, and perhaps indefinitely, screening in health care facilities and other public places will be the new normal. When you come to a hospital or clinic, expect to have your temperature taken and answer screening questions. These are for everyoneâ € ™ s safetyâ € "patients and caregivers.No health professionals need to be reminded of the seriousness of what lies ahead. Let us take what we have learned, be ready and ready to adaptâ €" and build one new determination to defeat this virus together ..

Zestril 10mg image

None How zestril 10mg picture you could cite this you could try this out article: Singh O P. Aftermath from Celebrity Suicide â € “Media coverage and role of psychiatrist. Indian Jutta Schröder (62) is one of the most prominent personalities in our country zestril 10mg image.

Indians got a glimpse of this after an unfortunate incident where a popular Hindi film actor died of suicide., As expected, the media got into a frenzy when newspapers, news networks and social media were full of stories that provided up-to-the-minute details of the suicide act. Some even zestril 10mg image so far as to highlight the color of the fabric used in the suicide as well as to show the actor's lifeless body. All kinds of personal information were unearthed, and speculation and hypotheses became the order of the day for the next few days., In the process, the reputations of many people related to the actor were tarnished and their private and personal details were freely and openly aired and discussed over electronic, print and social media.

We understand that media houses have their own needs and duties to report and sensationalize news in order to increase your visibility (aka TRP), but such coverage has a huge impact on the mental health of the population at risk quickly recognized when copycat criminals were reported from across the country from across the country within days., Psychiatrists suddenly began to get emergency calls from their patients in desperation with heightened thoughts of suicide. This has become a major concern for the psychiatric community, and the Indian Psychiatric Society has traditionally sought to use media to promote ethical coverage of suicide. Section 24 (1) of the Mental Health Act 2017 prohibits the publication of photos of mentally ill people without his consent., [1] zestril 10mg image The press council in India has adopted the guidelines of the World Health Organization Report on Preventing Suicide.

A resource for the media professionals who came up with a recommendation to be followed by the media in reporting cases of suicide. It contains points that prohibit you from putting stories in prominent positions and zestril 10mg image overly repeating, explicitly describing the method used, giving details about the website / location, using sensational headlines, or using photos and video recordings of the incident., [2] Unfortunately, the advice seems to have little effect in the aftermath of celebrity To have suicides. Channels were full of speculation about the person's mental health and illness, as well as his relationships and finances.

Many fictional reports about his symptoms and illness were touted, which is not only against ethics, but also against MHCA, 2017. [1] It went so far that the name of his psychiatrist was mentioned and quotes to him without taking him into account The Indian Psychiatric Society has written The Press Council in India underscores this concern and calls for action to ensure ethics in reporting suicide. While it is necessary to engage with media to help you understand the grave effects of negative suicide reporting To raise awareness of the lives of many at risk, there is an even more urgent need for training psychiatrists in how to properly interact with the media. This was brought abundantly in the wake of this incident., Many psychiatrists and psychologists have been encouraged by media outlets to comment on the episode. Many psychiatrists have been 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 have even been stories with a psychiatrist's byline where the content was not only unscientific but also went well beyond the expertise of a psychiatrist., These types of views perpetuate stigma, myths, and “misleading concepts” about psychiatry and are detrimental to the image of psychiatry adds harm and injustice to ours zestril 10mg image Patient. Hence the need to formulate a guideline for psychiatrists' interaction with the media is imperative. In the infamous Goldwater episode, 12,356 psychiatrists were asked to cast opinions on Barry Goldwater's fitness for running for president. Of 2,417 respondents, 1,189 psychiatrists said he was mentally incapable of being mentally ill 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 zestril 10mg image experienced the same phenomenon at the time of Donald Trump's presidential candidacy. Psychiatrists should be encouraged to interact with the media to provide scientific information on mental illness and stigma reduction, but "statements to the media" can be a double-edged one Be sword and we should know about the rules of engagement and limits of interactions.

Media interaction methods and principles should be part of our curriculum., Many professional societies have guidelines and resource books for media interaction, and psychiatrists should familiarize themselves with these documents. The press council should zestril 10mg image Urging reporters to seek psychiatrists for their opinion. It is useful for you to have a template ready with suicide rates, emphasizing multicausality of suicide, role of mental disorders, as well as assistance available., [5] It is time that the Indian Psychiatric Society formulated its own guidelines The General Principles and Limits for Interaction by Indian Psychiatrists with the Media., oad Principles: It should be assumed that no statement goes "off the record" since the media person is most likely recording the interview, and us Should such a conversation be out of our endIt should be clarified in what capacity comments are made - professionally, in person, or as a representative of an organization; a person who has not been investigated psychiatrists should take every opportunity to speak to the public about mental health issues educate the comments should be justified and limited by the limits of the scientific en knowledge to be available at the moment., references correspondence address.

Dr. O P SinghAA 304, Ashabari Apartments, O / 31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal Indian Source of Support. None, conflict of interest.

NoneDOI. 10.4103 / Psychiatrie.IndianJPsychiatry_816_20Abstract Electroconvulsive Therapy (ECT) is an effective form of treatment for a wide variety of psychiatric conditions. However, it has always been accused of being a compulsive, unethical, and dangerous method of treatment.

The dangerousness of ECT has been largely attributed to its claimed ability to cause brain damage., This narrative review aims to provide an update on the evidence as to whether the practice of ECT has been linked to brain damage. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that specifically address this issue.

While there are newer technological tools and innovations, any review attempting to answer this question would have to resort to indirect methods, which 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 the literature and evidence suggests that ECT has a demonstrable impact on the structure and function of the brain. However, there is currently a lack of evidence to suggest that ect causes brain damage. Side Effects, Brain Damage, Electroconvulsive Therapy as one cites this article: Jolly AJ, Singh SM., Electroconvulsive Therapy Causes Brain Damage.

An update. Indian J Psychiatry 2020. 62.

339-53 Introduction of electroconvulsive therapy (ECT) as a treatment method for psychiatric disorders has existed at least since 1938. [1] ECT is an effective treatment for various psychiatric disorders. From its inception, however, the practice of ECT has also encountered opposition from various groups claiming that it is compulsive and harmful of electrical current will be re-examined in the light of technological advances and new discoveries. [3] The question of whether ECT leads to brain damage has been examined, in a holistic manner, by Devanand et al. In the mid-1990s., [4], [5] The authors had attempted to answer this question by examining the effects of ECT on the brain in different areas - cognitive side effects, structural neuroimaging studies, neuropathologic studies of patients who had received ECT, autopsy studies of epilepsy patients, and finally animal ECS studies.

The authors had concluded that ECT does not cause brain damage. This narrative review aims to update the evidence on whether ect causes brain damage by reviewing relevant literature from 1994 to the present day., Framing the Question the Oxford Dictionary defines Damage as physical damage that increases the value, benefits, or affects the normal function of something. [6] Among medical dictionaries, the Peter Collins Dictionary defines damage as damage done to something (noun) or something (verb). [7] Brain damage is defined by the British Medical Association Medical Dictionary as the degeneration and death of nerve cells and pathways in the brain that may be localized to a specific area of ​​the brain or diffuse. [8] Based on such a definition, brain damage is related Using ECT should focus on death or degeneration of brain tissue, which results in impaired brain function. The importance of precisely defining brain damage will become apparent later in this review. There are now many more tools available to study the structure and function of the brain in health and disease. However, there are obvious ethical questions in the design of human studies designed to answer this specific question., Hence, one must necessarily resort to indirect evidence available from studies designed to answer other research questions.

These studies used the following methods. Structural neuroimaging studies, functional neuroimaging studies, metabolic neuroimaging studies, body fluid biochemical marker studies, and cognitive impairment studies More advanced neuroimaging techniques focus more on a mechanistic understanding of ECT., Therefore, the primary aim of later neuroimaging studies was to look for structural and functional brain changes that might explain how ECT works, rather than evidence of gross structural damage in itself. [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 of the effects of ECT on the brain, [4] of which two were pneumoencephalography studies, nine computed tomography (CT) studies, and five magnetic resonance imaging (MRI) studies. However, most of these studies were retrospective in design, performing neuroimaging in patients who had previously received ECT.

In the absence of baseline neuroimaging, it would be very difficult to ascribe structural changes to the brain to ECT. In addition, pneumoencephalography, CT scan, and even early 0.3 T MRI images provided much lower spatial resolution than today., The authors concluded that there was no evidence to show that the ECT did not cause structural damage to the brain. [4] Since then, at least twenty other MRI-based structural neuroimaging studies have examined the effects of ECT on the brain. The earliest MRI studies in the early 1990s focused on detecting structural damage after ECT.

All of these studies were prospective in design, with the first MRI scan performed at baseline and a second MRI scan after ECT., [9], [11], [12], [13], [41] while most studies the patients once at 24 h after ect recordings, some studies carried out several post-ect neuroimaging in the first 24 h after ECT in order to better capture the acute changes. A single study by Coffey et al. Follow-up of the patient for 6 months and repeated neuroimaging again after 6 months to capture any long-term changes after ECT., [10] The main conclusion that emerged from these early studies was that there was no evidence of cortical atrophy , Changes in ventricular size, or an increase in white matter hyperintensities. [4] The next key conclusion was that there appeared to be an increase in T1 and T2 relaxation times immediately after ECT, which returned to normal within 24 h.

This supports the theory that immediately after ECT, there appears to be a short-term failure of the bloodâ € “brain barrier, resulting in water influx into the brain tissue., [11] The last significant observation by Coffey et al. In 1991 it was found that there were no significant changes over time in the total volumes of the frontal lobes, temporal lobes, or amygdalaâ € “hippocampal complex. [10] However, this was later refuted by high-resolution MRI studies. Nonetheless, an inescapable conclusion from these early studies was that there were no 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 not observe any obvious changes in brain tissue after ECT. [17] The next big breakthrough came in 2010, when Nordanskog et al. Shown that there was a significant increase in the volume of the hippocampus bilaterally after a course of ECT in a cohort of patients with depressive disorders. [18] This contradicted the earlier observations of Coffey et al. That there was no increase in volume in any part of the brain after ECT., [10] This was quite an exciting search and was followed by some similar studies.

However, the perspective of these studies was very different from the early studies. In contrast to the early studies that looked for ect-related brain damage, the more recent studies focused more on elucidating the mechanism of action of ECT. Further in 2014, Nordanskog et al.

A follow-up study showed that although there was a significant increase in the volume of the hippocampus 1 week after a course of ECT, the hippocampus volume returned to baseline after 6 months., [19] Two more studies in 2013 showed that in addition to the hippocampus, the amygdala also showed a significant increase in volume after ECT., in the hippocampus, amygdala, anterior temporal pole, subgenual cortex, [21] right caudate nucleus and the entire medial temporal lobe (MTL), consisting of hippocampus, amygdala, and insula posterosuperem temporal cortex, [24] para hippocampi, right subgenual anterior cingulate gyrus and right anterior cingulate gyrus, [25] left cerebellar region VIIa crus I, [29] putamen, caudate nucleus and nucleus acumbens [31] and clusters with increased cortical thickness, which include the temporal pole, middle and upper temporal cortex, insula, and lower temporal cortex., [27] was the most commonly reported and replicated finding However, the bilateral increase in the hippocampal and amygdala volumes. In light of these findings, it has been tentatively suggested that ECT works by promoting neural regeneration in the hippocampus-amygdala complex. [42], [43] However, there are certain inconsistencies with this hypothesis. To date, only one study - Nordanskog et al., 2014 - has tracked patients participating in the study for a long period - 6 months in your case., And significantly, the authors found that the hippocampus volume was after an increase of 6 months immediately after ECT returns to baseline. [19] However, this was not linked to the relapse of depressive symptoms.

Another area of ​​significant confusion has been the correlation of hippocampal volume increases with improvement in depressive symptoms. Although almost all studies show a significant increase in the hippocampus volume after ECT, a majority of the studies could not demonstrate a correlation between symptom improvement and increase in hippocampus volume., [19], [20], [22], [24], [28] A significant minority of However, volumetric studies has demonstrated a correlation between an increase in hippocampal and / or amygdala volume and an improvement in symptoms. [21], [25], [30] Another set of studies uses diffusion tensor imaging, functional MRI (fMRI ), anatomical connectom, and structural network analysis to study the effect of ECT on the brain. The first of these studies by Abbott et al.

In 2014 it was shown that at fMRI the connectivity between the right and left hippocampus was significantly reduced in patients with severe depression. It was also shown that the connectivity was normalized after ECT, and the improvement in symptoms was correlated with a Increase in connectivity. [22] In a first of its kind DTI study, Lyden et al. In 2014, fractional anisotropy, which is a measure of white matter or fiber density, was shown to be increased in patients with severe depression in the anterior cingulum, forceps minor, and the dorsal aspect of the left upper longitudinal fasciculus post ECT., 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, built in 2015, large-scale anatomical networks of the human brain - connectomes, based on white matter fiber tractography. The authors found significant reorganization in the anatomical connections with the limbic structure, temporal lobes, and frontal lobes.

It was also found that the connection alternation between amygdala and ABS hippocampus correlated with the reduction in depressive symptoms., [26] In 2016, Wolf et al. Uses 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 cingulum (ACC / MPFC) network, MTL network, bilateral thalamus and left cerebellar regions / precuneus showed significant difference between the healthy volunteers and the patient group., It was also shown that The administration of ECT results in a significant increase in the network strength of the ACC / MPFC network and the MTL network, although the increase in network strength and symptom improvement were not correlated. [32] Building on these studies, a recently published meta-analysis has attempted a quantitative synthesis of changes in brain volume â € "" focus on hippocampal volume increase after 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 a significant increase in the volume of the right and left hippocampus after ECT. For the rest of the brain regions, the heterogeneity in protocols and imaging techniques did not allow quantitative analysis, and the authors resorted to a narrative review similar to the present one with similar conclusions. [44] Focusing solely on hippocampal volume change in ECT, Oltedal et al., In 2018 performed a mega-analysis of 281 patients with major depressive disorder treated with ECT at ten different global locations of the Global ECT-MRI Research Collaboration. [45] Similar to previous studies, there was a significant increase in bilateral hippocampal volume with a dose-response relationship with the number of ECTs administered. In addition, bilateral (B / L) ect was associated with an even increase in volume in the right and left hippocampus, while right unilateral ECT was associated with a greater increase in volume in the right hippocampus., Finally, contrary to expectation, it was found that the clinical improvement was negative with the Thus, a review of the current evidence amply reveals that by searching for ect-related brain damage - and not finding any, we have now moved on in search of a mechanistic understanding of the effects of ECT.

In this regard, it was found that ECT does not induce structural changes in the brain - a fact that has been confiscated, on some to claim, ECT leads to brain damage., [46] Such statements, however, should contradict the definition of damage as used scientific medical community and the patient population. Neuroanatomical changes associated with more effective ECT can be better described as ECT-induced brain neuroplasticity or ect-induced brain neuromodulation than ECT-induced brain damage. Metabolic Neuroimaging Studies.

Magnetic Resonance Spectroscopic Imaging Magnetic resonance spectroscopic imaging (MRSI) uses a phase encoding technique to map the spatial distribution of magnetic resonance signals from different molecules., The key difference, however, is that while MRI maps the MR signals from water molecules, mrsi maps the MR signals from different ones Metabolites such as N-acetyl aspartate (NAA) and compounds containing choline are produced. However, the concentration of these metabolites is at least 10,000 times lower than water molecules and therefore the signal strength generated would also be correspondingly lower. However, MRSI offers us the unique advantage of studying the change in the concentration of brain metabolites in vivo, which is in areas such as psychiatry, neurology and Basic neuroscientific research was of great importance. [47] MRSI studies of ECT in patients with depression have largely focused on four metabolites in the human brain â € “" NAA, choline-containing compounds (Cho), which are predominantly cell membrane compounds such as glycerophosphocholine, and phosphocholine contain a minimal contribution of acetylcholine, creatinine (Cr), and glutamine and glutamate combined (Glx)., NAA resides exclusively in neurons and is suggested as a marker of neuronal viability and functionality. [48] Choline-containing compounds (Cho) mainly comprise the membrane connection en, and an increase in Cho would be suggestive of increased membrane turnover. Cr serves as a marker for cellular energy metabolism, and its values ​​are usually expected to remain stable.

The regions most frequently examined in MRSI studies include the bilateral hippocampus and amygdala, the dorsolateral prefrontal cortex (DLPFC), and ACC., To date, five MRSI studies have measured the NAA concentration in the hippocampus before and after ECT . Of these, three studies showed that the NAA concentration in the hippocampus does not change significantly after ECT. [33], [38], [49] on the other hand, two current studies show a statistically significant reduction in the NAA concentration in the hippocampus after ECT [39], [40] The implications of these results are of considerable interest to us in answering the eponymous question., A normal level of NAA after ECT could mean that there is no significant neural death or damage after ECT, while a reduction would signal the opposite. However, a direct comparison between these studies is complicated mainly due to the different ect protocols used in these studies.

It must be recognized, however, that the three older studies used 1.5 T MRI, while the two newer studies used a higher 3 T MRI, which had a better signal-to-noise ratio and therefore a lower risk of errors in measuring metabolite concentrations offers., 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 that a reduced NAA might indicate a change in the ratio of mature to immature neurons, which in fact is Might reflect improved adult neurogenesis. Thus, the authors warn that inferring whether a decrease in NAA concentration is beneficial or harmful requires a simultaneous measurement of cognitive function, which their study lacked. In 2017, Cano et al., There was also a significant reduction in the NAA / Cr ratio in the hippocampus post ECT.

More significantly, the authors also showed a significant increase in the Glx level in the hippocampus after ECT, which was also associated with an increase in the hippocampal volume. [40] To explain these three findings, the authors suggested, ECT produces a neuroinflammatory response in the hippocampus - probably mediated by Glx, which is known to cause inflammation, at higher concentrations, thereby accounting for the increase in hippocampal volume with one Reduction of the NAA concentration., The cause of the volume increase remains unclear - with the authors speculating that it could be due to neuronal swelling or due to angiogenesis. The same study and several other previous studies [21], [25], [30] have shown that hippocampal volume increase was correlated with clinical improvement after ECT. Thus we are led to the hypothesis that the same mechanism that drives clinical improvement with ECT is also responsible for the cognitive impairment after ECT, whether that is a purely neuroinflammatory response or a neuroplastic response or a neuroinflammatory response leading to a form neuroplasticity is a critical question that remains to be answered. [40] Studies analyzing changes in NAA levels in other areas of the brain have also produced conflicting results.

The ACC is another area that has been studied in some detail using the MRSI technique. In 2003, Pfleiderer et al. There was demonstrably no significant change in the NAA and Cho values ​​in the ACC following ECT. This seems to indicate that there was no neurogenesis or membrane turnover in the ACC post ECT. [36] however, this finding was made by Merkl et al.

Contested. In 2011, it demonstrated that the NAA values ​​were significantly reduced in the left ACC in patients with depression and that these levels were significantly increased after ECT. [37] this is in turn by Njau et al. Contested.

Who showed that the NAA levels after ECT in the left ACC spine are significantly reduced., [39] A direct comparison of these three studies is made difficult by the different ect and imaging parameters used, so that no firm conclusion can be drawn at this point in time can. In addition, one study showed increased NAA values ​​in the amygdala after administration of ECT [34] with a trend increase in Cho values, which in turn suggests neurogenesis and / or neuroplasticity. A review of the studies on the DLPFC shows a similarly confusing picture with a study that did not change, reduce or increase the concentration of NAA after ECT., [35], [37], [39] also Here is a direct comparison of the Three studies complicated by the heterogeneous imaging and ECT protocols. A total of five studies analyzed the concentration of choline-containing compounds (Cho) in patients who took ECT.

Conceptually, an increase in Cho signals suggests increased membrane turnover, which is associated with synaptogenesis, neurogenesis, and maturation of neurons. [31] Of these, two studies measured the Cho concentration in the B / L hippocampus with contrasting results. Ende et al., In 2000 showed a significant increase in Cho values ​​in B / L hippocampus after ECT, while Jorgensen et al. The same finding could not be replicated in 2015. [33], [38] Cho planes were also examined in the amygdala, ACC, and DLPFC.

However, none of these studies showed a significant increase or decrease in Cho values ​​before and after ECT in the respective brain regions examined. In addition, no significant difference was seen in the pre-ECT-Cho levels of the patients compared to healthy controls., [34], [36], [37] In retrospect, we must admit that the MRSI studies are still in a preliminary stage with significant heterogeneity in ect protocols, patient population and examined brain regions. At this stage it is difficult to draw firm conclusions other than the fact that the more recent studies - Njau et al., 2017, Cano, 2017 and Jorgensen et al., 2015 - have shown decreases in NAA concentration and no increase in Cho levels [38], [39], [40] â € “in contrast to the earlier studies by Ende et al., [33] The view offered by the more recent studies is one of One of the neuroinflammatory models of the action of ECT, likely driving neuroplasticity in the hippocampus.

This would provide a mechanistic understanding of the clinical response and the phenomenon of cognitive impairment associated with ECT. However, this conclusion is based on guesswork and more needs to be done in this area. Another line of evidence for analyzing the effects of ECT on the human brain is to study the concentration of neurotrophins in the plasma or serum., Neurotrophins are small protein molecules that mediate neuronal survival and development.

The most prominent among these is brain-derived neurotrophic factor (BDNF), which plays an important role in neural survival, plasticity, and migration. [50] A neurotrophic theory of mood disorders has been proposed, hypothesizing that depressive disorders are associated with decreased expression of BDNF in the limbic structures, causing the atrophy of these structures., [51] It has also been postulated that antidepressant treatment has a neurotrophic effect which reverses neuronal cell loss and thereby produces a therapeutic effect. It has been well established that BDNF decreases in mood disorders. [52] It has also been shown that clinical improvement in depression is associated with increases in BDNF levels. [53] Therefore, serum BDNF levels have been tentatively proposed as a biomarker for the treatment of depression., Recent meta-analytical evidence has shown that ECT is associated with a significant increase in serum BDNF levels in patients with major depressive disorder. [54] Given that BDNF is a potent stimulator of neurogenesis, the increase in serum BDNF levels after ECT adds further credibility to the theory that ECT leads to neurogenesis in the hippocampus and other limbic structures, which in turn mediates the therapeutic effects of ECT.Cognitive Impairment Studies Cognitive impairment has always been the main side effect associated with ECT., [55] Soon after the introduction of ECT, concerns about long-term cognitive impairment emerged and has since become one of the most controversial aspects of ECT. [56] Anti-ECT groups have often pointed to cognitive impairments after ECT as evidence of ect brain damage. [56] a 2010 meta-analysis by Semkovska and McLoughlin is one of the most detailed studies that attempted to resolve this longstanding debate., [57] The authors reviewed the 84 studies (2981 participants) that had used a total of 22 standardized neuropsychological tests Assessment of various cognitive functions before and after ECT in patients with major depression.

The various cognitive domains reviewed including processing speed, attention / working memory, verbal episodic memory, visual episodic memory, spatial problem solving, executive function, and mental ability., The authors concluded that the administration of ECT for depression is associated with significant cognitive functions Impairments in the first few days after ECT administration. However, it was also seen that impairments in cognitive function resolved within a period of 2 weeks and afterwards a majority of cognitive domains showed even slight improvement compared to baseline performance. It was also demonstrated that not a single cognitive domain showed persistence of impairment beyond 15 days after ECT., Memory disorders after ECT can be analyzed broadly under two conceptual schemes - one that classifies memory disorders as objective memory impairment and subjective impairment Memory and the others that it classifies as impairment in anterograde memory versus impairment in retrograde memory.

Objective memory can be broadly 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 the ability to retrieve stored information., [58] As previously described, it has been conclusively demonstrated that anterograde memory impairment does not last longer than 2 weeks after ECT. [57] However, one of the main limitations of this meta-analysis has been the lack of evidence of retrograde amnesia after ECT. This is particularly unfortunate when one considers that it is memory impairment - particularly retrograde amnesia, which has received the most attention. [59] Furthermore, reports of catastrophic retrograde amnesia have repeatedly been withheld as sensational evidence of the permanent brain damage from ECT., [59] Granted, studies on retrograde amnesia are less and less conclusive than on anterograde amnesia. [60], [61] currently the results are contradicting, with some studies finding some impairments in retrograde memory - particularly retrograde autobiographical memory up to 6 months after ECT. [62], [63], [64], [65] but recent studies have not supported this finding., [66], [67], while they show an impairment in retrograde memory immediately ECT, it was seen that this deficit returned pre-ECT levels within a period of 1–2 months and also improved baseline performance after 6 months post ECT. [66] There are also numerous factors that confuse the assessment of retrograde amnesia.