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Firstly, Martin attended can you buy viagra over the counter three viagra benefits training sessions in November. These comprised of a session covering placement logistics/ what to expect on their placement, followed by a session hearing from previous Fellow’s and Media hosts, and finally, a journalism ‘101’. All the Fellows were given a list of helpful resources and a copy of a book titled ‘The Craft of Science Writing’, recommended by a journalist. Martin will be placed at the Naked Scientists for 6 weeks, starting January 10, can you buy viagra over the counter 2021. The British Science Association’s Media Fellowships provide a unique opportunity for practicing scientists, clinicians and engineers to spend two to six weeks working at the heart of a media outlet such as The Guardian, BBC Breakfast or Sky News.

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Public engagement with biomedical science is so important, especially in the current climate, and I hope that my new position and skills in science communication can support biomedical scientists to better promote the vital job they do in NHS trusts across the country. To be given this opportunity is the culmination of many years of developing myself as a public engagement specialist for STEM and to say that I am excited and proud is just not enough words!. I would just like to say a massive thank you to the IBMS and the BSA can you buy viagra over the counter for giving me this opportunity. I’ll do you proud I promise!. € Due to the viagra situation, the 2020 fellowship programme was pushed back until January 2021.17 December 2020 The WHO Academy Team has developed an app to highlight the critical importance of PPE The WHO Academy has launched its first augmented reality course for health workers on the proper use of personal protective equipment (PPE).

This short can you buy viagra over the counter course is available on the Academy’s mobile learning app for all health workers globally. The course is free and can be taken from a smartphone anywhere, anytime. It takes about 20 mins to complete and is available in 7 languages - Arabic, Chinese, English, French, Portuguese, Russian and Spanish. Try the course can you buy viagra over the counter now!. What is the WHO Academy’s new PPE course?.

Using augmented reality technology, the WHO Academy is now offering a free 20-minute course for health workers that demonstrates the proper techniques and sequence to put on and remove their personal protective equipment (PPE) equipment, which are critical to keeping them safe. The course is available via the Academy’s mobile learning app, which is available for can you buy viagra over the counter download from both the Google Play and Apple App stores. What does Augmented Reality (AR) mean?. Augmented reality is a technology that superimposes a computer-generated image on a user’s real-world view. In the case of this PPE course, learners can project the 3D animated nurse in the room or space where can you buy viagra over the counter they are with their smartphone.

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How to Generic levitra best price cite this article:Singh viagra at cvs O P. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J viagra at cvs Psychiatry 2020;62:337-8Celebrity suicide is one of the highly publicized events in our country.

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

All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the actor were besmirched and their private and personal details were freely and blatantly broadcast and discussed on electronic, viagra at cvs print, and social media. We understand that media houses have their own need and duty to report and sensationalize news for increasing their visibility (aka TRP), but such reporting has huge impacts on the mental health of the vulnerable population.The impact of this was soon realized when many incidents of copycat suicide were reported from all over the country within a few days of the incident.

Psychiatrists suddenly started getting distress calls from their patients in despair with increased suicidal ideation viagra at cvs. 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 viagra at cvs 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 viagra at cvs 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 viagra at cvs India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the proper way of interaction with media. This has been amply brought out in the aftermath of this incident.

Many psychiatrists and mental health viagra at cvs 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 psychiatry and are detrimental to the image of psychiatry viagra at cvs 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 viagra at cvs to interact with media to provide scientific information about mental illnesses and reduction of stigma, but “statements to the media” can be a double-edged sword, and we should know about the rules of engagements and boundaries of interactions.

Methods and principles of interaction with media should form a part of our training curriculum. Many professional societies have guidelines and resource books for interacting with media, viagra at cvs 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 viagra at cvs desirable to be guided by the following broad principles:It should be assumed that no statement goes “off the record” as the media person is most likely recording the interview, and we should also record any such conversation from our endIt should be clarified in which capacity comments are being made – professional, personal, or as a representative of an organizationOne should not comment on any person whom he has not examinedPsychiatrists should take any such opportunity to educate the public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource viagra at cvs 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 https://www.wolf-garten.com/generic-levitra-best-price cite this article:Singh O P can you buy viagra over the counter. Aftermath of celebrity suicide – Media coverage and role of psychiatrists. Indian J Psychiatry 2020;62:337-8Celebrity can you buy viagra over the counter suicide is one of the highly publicized events in our country. Indians got a glimpse of this following an unfortunate incident where a popular Hindi film actor died of suicide. As expected, can you buy viagra over the counter the media went into a frenzy as newspapers, news channels, and social media were full of stories providing minute details of the suicidal act.

Some even going as far as highlighting the color of the cloth used in the suicide as well as showing the lifeless body of the actor. All kinds of personal details were dug up, and speculations and hypotheses became the order of the day in the next few days that followed. In the process, reputations of many people associated with the can you buy viagra over the counter 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 can you buy viagra over the counter 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 can you buy viagra over the counter 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 can you buy viagra over the counter and also his relationships and finances.

Many fictional accounts of his symptoms and illness were touted, which is not only against the ethics but is also contrary to MHCA, 2017.[1]It went to the extent that the name of his psychiatrist was mentioned and quotes were attributed to him without taking any account from him. The Indian Psychiatric Society has written to the Press Council of India underlining this concern and asking for measures to ensure ethics in reporting suicide.While there is a need for engagement with media to make them aware of the grave impact of negative suicide reporting on the lives of many vulnerable persons, there is even a more urgent need for training of psychiatrists regarding the can you buy viagra over the counter proper way of interaction with media. This has been amply brought out in the aftermath of this incident. Many psychiatrists and mental health professionals were called by media houses can you buy viagra over the counter 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 can you buy viagra over the counter stigma, myths, and “misleading concepts” about 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 can you buy viagra over the counter 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 boundaries of interactions. Methods and principles of interaction with media should form a part of our training curriculum.

Many professional can you buy viagra over the counter 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 can you buy viagra over the counter to educate the public about mental health issuesThe comments should be justified and limited by the boundaries of scientific knowledge available at the moment. References Correspondence Address:Dr.

O P SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West can you buy viagra over the counter 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. Electroconvulsive therapy.

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A proton magnetic resonance study of the left amygdalar region in patients with treatment-resistant depression. Neuropsychopharmacology 2003;28:720-5. 36.Pfleiderer B, Michael N, Erfurth A, Ohrmann P, Hohmann U, Wolgast M, et al. Effective electroconvulsive therapy reverses glutamate/glutamine deficit in the left anterior cingulum of unipolar depressed patients. Psychiatry Res 2003;122:185-92.

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

Acta Psychiatr Scand 2016;133:154-64. 39.Njau S, Joshi SH, Espinoza R, Leaver AM, Vasavada M, Marquina A, et al. Neurochemical correlates of rapid treatment response to electroconvulsive therapy in patients with major depression. J Psychiatry Neurosci 2017;42:6-16. 40.Cano M, Martínez-Zalacaín I, Bernabéu-Sanz Á, Contreras-Rodríguez O, Hernández-Ribas R, Via E, et al.

Brain volumetric and metabolic correlates of electroconvulsive therapy for treatment-resistant depression. A longitudinal neuroimaging study. Transl Psychiatry 2017;7:e1023. 41.Figiel GS, Krishnan KR, Doraiswamy PM. Subcortical structural changes in ECT-induced delirium.

J Geriatr Psychiatry Neurol 1990;3:172-6. 42.Rotheneichner P, Lange S, O'Sullivan A, Marschallinger J, Zaunmair P, Geretsegger C, et al. Hippocampal neurogenesis and antidepressive therapy. Shocking relations. Neural Plast 2014;2014:723915.

43.Singh A, Kar SK. How electroconvulsive therapy works?. Understanding the neurobiological mechanisms. Clin Psychopharmacol Neurosci 2017;15:210-21. 44.Gbyl K, Videbech P.

Electroconvulsive therapy increases brain volume in major depression. A systematic review and meta-analysis. Acta Psychiatr Scand 2018;138:180-95. 45.Oltedal L, Narr KL, Abbott C, Anand A, Argyelan M, Bartsch H, et al. Volume of the human hippocampus and clinical response following electroconvulsive therapy.

Biol Psychiatry 2018;84:574-81. 46.Breggin PR. Brain-Disabling Treatments in Psychiatry. Drugs, Electroshock, and the Role of the FDA. New York.

Springer Pub. Co.. 1997. 47.Posse S, Otazo R, Dager SR, Alger J. MR spectroscopic imaging.

Principles and recent advances. J Magn Reson Imaging 2013;37:1301-25. 48.Simmons ML, Frondoza CG, Coyle JT. Immunocytochemical localization of N-acetyl-aspartate with monoclonal antibodies. Neuroscience 1991;45:37-45.

49.Obergriesser T, Ende G, Braus DF, Henn FA. Long-term follow-up of magnetic resonance-detectable choline signal changes in the hippocampus of patients treated with electroconvulsive therapy. J Clin Psychiatry 2003;64:775-80. 50.Bramham CR, Messaoudi E. BDNF function in adult synaptic plasticity.

The synaptic consolidation hypothesis. Prog Neurobiol 2005;76:99-125. 51.Duman RS, Monteggia LM. A neurotrophic model for stress-related mood disorders. Biol Psychiatry 2006;59:1116-27.

52.Bocchio-Chiavetto L, Bagnardi V, Zanardini R, Molteni R, Nielsen MG, Placentino A, et al. Serum and plasma BDNF levels in major depression. A replication study and meta-analyses. World J Biol Psychiatry 2010;11:763-73. 53.Brunoni AR, Lopes M, Fregni F.

A systematic review and meta-analysis of clinical studies on major depression and BDNF levels. Implications for the role of neuroplasticity in depression. Int J Neuropsychopharmacol 2008;11:1169-80. 54.Rocha RB, Dondossola ER, Grande AJ, Colonetti T, Ceretta LB, Passos IC, et al. Increased BDNF levels after electroconvulsive therapy in patients with major depressive disorder.

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

Lancet 2003;361:799-808. 56.57.Semkovska M, McLoughlin DM. Objective cognitive performance associated with electroconvulsive therapy for depression. A systematic review and meta-analysis. Biol Psychiatry 2010;68:568-77.

58.Tulving E, Madigan SA. Memory and verbal learning. Annu Rev Psychol 1970;21:437-84. 59.Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy.

Systematic review. BMJ 2003;326:1363. 60.Semkovska M, McLoughlin DM. Measuring retrograde autobiographical amnesia following electroconvulsive therapy. Historical perspective and current issues.

J ECT 2013;29:127-33. 61.Fraser LM, O'Carroll RE, Ebmeier KP. The effect of electroconvulsive therapy on autobiographical memory. A systematic review. J ECT 2008;24:10-7.

62.Squire LR, Chace PM. Memory functions six to nine months after electroconvulsive therapy. Arch Gen Psychiatry 1975;32:1557-64. 63.Squire LR, Slater PC. Electroconvulsive therapy and complaints of memory dysfunction.

A prospective three-year follow-up study. Br J Psychiatry 1983;142:1-8. 64.Squire LR, Slater PC, Miller PL. Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up.

Arch Gen Psychiatry 1981;38:89-95. 65.Squire LR, Wetzel CD, Slater PC. Memory complaint after electroconvulsive therapy. Assessment with a new self-rating instrument. Biol Psychiatry 1979;14:791-801.

66.Calev A, Nigal D, Shapira B, Tubi N, Chazan S, Ben-Yehuda Y, et al. Early and long-term effects of electroconvulsive therapy and depression on memory and other cognitive functions. J Nerv Ment Dis 1991;179:526-33. 67.Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities.

Arch Gen Psychiatry 2000;57:425-34. 68.Abrams R. Does brief-pulse ECT cause persistent or permanent memory impairment?. J ECT 2002;18:71-3. 69.Peretti CS, Danion JM, Grangé D, Mobarek N.

Bilateral ECT and autobiographical memory of subjective experiences related to melancholia. A pilot study. J Affect Disord 1996;41:9-15. 70.Weiner RD, Rogers HJ, Davidson JR, Squire LR. Effects of stimulus parameters on cognitive side effects.

Ann N Y Acad Sci 1986;462:315-25. 71.Prudic J, Peyser S, Sackeim HA. Subjective memory complaints. A review of patient self-assessment of memory after electroconvulsive therapy. J ECT 2000;16:121-32.

72.Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993;328:839-46. 73.Frith CD, Stevens M, Johnstone EC, Deakin JF, Lawler P, Crow TJ. Effects of ECT and depression on various aspects of memory.

Br J Psychiatry 1983;142:610-7. 74.Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, et al. Efficacy and cognitive effects of right unilateral electroconvulsive therapy. J ECT 2000;16:370-9. 75.Coleman EA, Sackeim HA, Prudic J, Devanand DP, McElhiney MC, Moody BJ.

Subjective memory complaints prior to and following electroconvulsive therapy. Biol Psychiatry 1996;39:346-56. 76.Berggren Š, Gustafson L, Höglund P, Johanson A. A long-term longitudinal follow-up of depressed patients treated with ECT with special focus on development of dementia. J Affect Disord 2016;200:15-24.

77.Brodaty H, Hickie I, Mason C, Prenter L. A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord 2000;60:101-11. 78.Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB. Electroconvulsive therapy and risk of dementia in patients with affective disorders.

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

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

What side effects may I notice from Viagra?

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

  • allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
  • breathing problems
  • changes in hearing
  • changes in vision, blurred vision, trouble telling blue from green color
  • chest pain
  • fast, irregular heartbeat
  • men: prolonged or painful erection (lasting more than 4 hours)
  • seizures

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

  • diarrhea
  • flushing
  • headache
  • indigestion
  • stuffy or runny nose

This list may not describe all possible side effects. Call your doctor for medical advice about side effects.

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To protect the people of NSW from the evolving erectile dysfunction treatment outbreak, new restrictions will be introduced for Greater Sydney from 4pm today for one week.Following updated health advice from the Chief Health Officer Dr Kerry Chant about the growing risk to the community, the following restrictions will be introduced for Greater Sydney, the Central Coast, Blue Mountains, Wollongong and Shellharbour;Visitors to households will be limited to 5 guests – including children;Masks will be compulsory in all indoor non-residential settings, including workplaces, and at organised outdoor events;Drinking while standing at indoor venues will not be allowed;Singing by audiences at indoor shows or by congregants at indoor places of worship will not be allowed;Dancing will not be allowed at indoor hospitality venues or nightclubs however, dancing is allowed at weddings for the bridal party only (no more than 20 people);Dance and gym classes limited to 20 per class (masks must be worn);The one person per four square metre rule will be re-introduced for all indoor and outdoor settings, including weddings and funerals;Outdoor seated events will be limited to 50% seated capacity;Previous public transport capacity limits, represented by green dots, will be reintroduced;If you live or work in the City of Sydney, Waverley, Randwick, Canada Bay, Inner West, Bayside, and Woollahra local government areas, you cannot travel outside metropolitan Sydney for non-essential travel.These restrictions are designed to reduce the risk of further community transmission.NSW Premier Gladys Berejiklian said we are once again asking the community to do what they do best and follow the health advice to get on top of this outbreak.“We don’t take these steps lightly and we never want to impose restrictions unless we absolutely have to,” Ms Berejiklian said.“We know the effect this will have on residents and venues but we must take this action now viagra super active to ensure we keep on top of this outbreak.”Chief Health Officer Kerry Chant urged the community to play their part in controlling the erectile dysfunction treatment spread.“We need really high testing rates to make sure we’re stopping any chains of transmission and we’re continuing to urge people to come forward for testing, especially if you were in Westfield Bondi Junction (including the car park) at any time between 12 June and 18 June,” Dr Chant said.Health Minister Brad Hazzard said more than ever people need to use QR codes and wear masks when required.“We will be increasing supervision and compliance checks to make sure everyone is doing the right thing,” Mr Hazzard said.“This viagra is far from over and we all have to do our bit to protect the community.”The government and health experts will continue to monitor the situation closely and provide updated information and advice.For more information visit the NSW Government website.NSW Health has received $30.2 billion in today’s Budget, demonstrating the NSW Government’s commitment to ensuring world-class health services for the community.More than $3 billion will be invested this year to build and redevelop hospitals and health facilities across NSW. 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That’s an extraordinary increase of more than 75 per cent,” Mr Perrottet said.“We continue to invest in patient-centred care, with brand new and upgraded facilities, the latest in cutting edge technologies and an ever-expanding health workforce.”Health Minister Brad Hazzard said the Budget reflects the NSW Government’s ongoing commitment to create healthy communities by bringing first-class facilities closer to home.“Purpose designed hospital and health facilities drive improved health outcomes and experiences for patients, their families and our dedicated health staff,” Mr Hazzard said.Key Highlights of the Budget include:$1.1 billion to continue the state’s response to erectile dysfunction treatment, including:$340.0 million to fund personal protective equipment (PPE) procurement and associated warehouse costs to keep our frontline workers safe;$261.3 million for erectile dysfunction treatment distribution$200.0 million for pop-up clinics, testing and contact tracing$145.4 million for returning travelers in quarantine requiring medical assistance;$80 million to continue additional elective surgery$30.0 million for the ongoing enhanced level of cleaning within health facilitiesThis takes the total commitment to the health system to manage the impacts of the erectile dysfunction treatment viagra to more than $4 billion since March 2020.$159.3 million in 2021-22 to fund services in newly constructed hospitals scheduled to open in 2021-22.More than $214.3 million to boost NSW Ambulance services, including:$126 million over four years to improve NSW Ambulance operations through a modern, integrated facility at Sydney Olympic Park;$54.3 million recurrent expenses over four years to enable NSW Ambulance to secure an improved mix of aircraft, including jet aircraft, to improve patient safety and access to emergency care;$34.0 million over four years to convert 246 paramedics to Intensive Care Paramedics, of which 80 per cent will be in regional New South Wales;Upgrade of in-ambulance defibrillators that improve electronic medical record integration capabilities between viagra super active NSW Ambulance and hospital emergency departments across the state and especially in regional areas in 2021-22.$109.5 million over four years to develop 25 ‘Safeguards’ – Child and Adolescent Mental Health Crisis Teams across NSW to provide services to children and adolescents with moderate to severe mental health issues and their families/carers;$82.8 million over four years to continue strengthening specialist palliative and end of life care, including improving community-based care, enhancing hospital services, consumer support, the regional and rural workforce and providing state supported scholarships in palliative care medicine;$36.4 million over four years for 57 mental health Response and Recovery Specialists across regional and rural New South Wales to provide assertive outreach support for communities, and coordination with local services at the time of a disaster or crisis, and during the ongoing recovery phase;$21.6 million over four years to provide a state-wide Transcatheter Aortic Valve Implementation (TAVI) service for high risk patients, including those in rural and remote areas of NSW;$12.2 million over two years to fund Tresillian for six Regional Family Care Centres as well as five ‘Tresillian 2U vans’ and staffing for the Macksville residential unit;$8.6 million over four years to support community care for people with movement disorders, such as Parkinson’s Disease by delivering specialist nurses and allied health staff in 15 Local Health Districts. This package also includes funding for Parkinson’s NSW to support their InfoLine service as well as additional teaching, training and capacity building;$7.7 million over four years to pilot a new model of care for children and young people with behavioural disorders including Attention Deficit Hyperactivity Disorder (ADHD) in two regional Local Health Districts;$3.0 million towards the establishment of ACON’s LGBTQ+ health centre to improve access to primary and community-based healthcare.NSW Health will invest $10.8 billion on capital viagra super active infrastructure over the next four years with a program of $3.2 billion in 2021-22.

This record investment will ensure the 29 new and upgraded hospitals and health facilities announced prior to the 2019 state viagra super active election will commence before March 2023. The funding also includes:$327 million for new works commencing in 2021-22 including nine hospital upgrades or redevelopments, two major Information Communication Technology projects, establishment of a HealthOne at Canowindra, and a number of NSW Ambulance related projects;Hospital upgrades and redevelopments including:$45 million for the Muswellbrook Hospital Stage 3 Redevelopment;an additional $50 million for the Sydney Children’s Hospitals viagra super active Network at Randwickan additional $15 million for Goulburn Hospital and commencement of the Ryde, Rouse Hill, Moree, Gunnedah, and Wentworth Hospital RedevelopmentsThis investment also includes funding in 2021-22 to progress the $10 million NSW paediatric cardiac enhancements across the Sydney Children’s Hospitals Network.Of this record investment, almost $2.5 billion will be allocated across the State to continue Health’s record capital program which includes 37 hospital upgrades or redevelopments (with four new hospitals) and eight regional and metropolitan car parks currently being built. In addition, the 2021-22 Budget includes $280.2 million for Information Communication Technology projects, $80 million for the asset refurbishment and replacement program and $109 million for works funded by local health districts and specialty health networks through the Locally Funded Initiatives Program.Hospital upgrades and redevelopments in progress include:Bankstown and Lidcombe Hospital ($1.3 billion)Nepean Hospital ($1.0 billion)John Hunter Hospital and car park ($835 million)Randwick Campus ($783 million)Royal Prince Alfred Hospital ($750 million)Liverpool Health and Academic Precinct, including carpark ($790 million)The new Shellharbour Hospital and Integrated Services ($699 viagra super active million)Tweed Hospital ($673 million)Campbelltown Hospital ($632 million)Children’s Hospital Westmead Stage 2 ($619 million)Sydney Children’s Hospital Randwick ($608 million)The new Maitland Hospital ($470 million)Shoalhaven Hospital ($438 million)Wagga Wagga Hospital ($431 million)St George Hospital ($385 million)Concord Hospital ($341 million)Lismore Base Hospital ($313 million)Dubbo Health Service ($306 million) andGriffith Base Hospital ($250 million).

To protect the people of NSW from the evolving erectile dysfunction treatment outbreak, new restrictions will be introduced for Greater Sydney from 4pm today for one week.Following updated health advice from the Chief Health Officer Dr Kerry Chant about the growing risk to the community, the following restrictions will be introduced for Greater Sydney, the Central Coast, Blue Mountains, Wollongong and Shellharbour;Visitors to households will be limited to 5 guests – including children;Masks will be compulsory in all indoor non-residential settings, including workplaces, and at organised outdoor events;Drinking while standing at indoor venues will not be allowed;Singing by audiences at indoor shows or by congregants at indoor places of worship will not be allowed;Dancing will not be allowed at indoor hospitality venues or nightclubs however, dancing is allowed at weddings for the bridal party only (no more than 20 people);Dance and gym classes limited to 20 per class (masks must be worn);The one person per four square metre rule will be re-introduced for all can you buy viagra over the counter Buy amoxil online usa indoor and outdoor settings, including weddings and funerals;Outdoor seated events will be limited to 50% seated capacity;Previous public transport capacity limits, represented by green dots, will be reintroduced;If you live or work in the City of Sydney, Waverley, Randwick, Canada Bay, Inner West, Bayside, and Woollahra local government areas, you cannot travel outside metropolitan Sydney for non-essential travel.These restrictions are designed to reduce the risk of further community transmission.NSW Premier Gladys Berejiklian said we are once again asking the community to do what they do best and follow the health advice to get on top of this outbreak.“We don’t take these steps lightly and we never want to impose restrictions unless we absolutely have to,” Ms Berejiklian said.“We know the effect this will have on residents and venues but we must take this action now to ensure we keep on top of this outbreak.”Chief Health Officer Kerry Chant urged the community to play their part in controlling the erectile dysfunction treatment spread.“We need really high testing rates to make sure we’re stopping any chains of transmission and we’re continuing to urge people to come forward for testing, especially if you were in Westfield Bondi Junction (including the car park) at any time between 12 June and 18 June,” Dr Chant said.Health Minister Brad Hazzard said more than ever people need to use QR codes and wear masks when required.“We will be increasing supervision and compliance checks to make sure everyone is doing the right thing,” Mr Hazzard said.“This viagra is far from over and we all have to do our bit to protect the community.”The government and health experts will continue to monitor the situation closely and provide updated information and advice.For more information visit the NSW Government website.NSW Health has received $30.2 billion in today’s Budget, demonstrating the NSW Government’s commitment to ensuring world-class health services for the community.More than $3 billion will be invested this year to build and redevelop hospitals and health facilities across NSW. This is can you buy viagra over the counter in addition to the more than $27 billion in recurrent funding. Treasurer Dominic Perrottet can you buy viagra over the counter said the record investment demonstrates the NSW Government’s commitment to the health of its people.“Since March 2011, recurrent funding for the NSW public health system has increased by almost $11.7 billion, up from $15.5 billion in 2010-11. That’s an extraordinary increase of more than 75 per cent,” Mr Perrottet said.“We continue to invest in patient-centred care, with brand new and upgraded facilities, the latest in cutting edge technologies and an ever-expanding health workforce.”Health Minister Brad Hazzard said the Budget reflects the NSW Government’s ongoing commitment to create healthy communities by bringing first-class facilities closer to home.“Purpose designed hospital and health facilities drive improved health outcomes and experiences for patients, their families and our dedicated health staff,” Mr Hazzard said.Key Highlights of the Budget include:$1.1 billion to continue the state’s response to erectile dysfunction treatment, including:$340.0 million to fund personal protective equipment (PPE) procurement and associated warehouse costs to keep our frontline workers safe;$261.3 million for erectile dysfunction treatment distribution$200.0 million for pop-up clinics, testing and contact tracing$145.4 million for returning travelers in quarantine requiring medical assistance;$80 million to continue additional elective surgery$30.0 million for the ongoing enhanced level of cleaning within health facilitiesThis takes the total commitment to the health system to manage the impacts of the erectile dysfunction treatment viagra to more than $4 billion since March 2020.$159.3 million in 2021-22 to fund services in newly constructed hospitals scheduled to open in 2021-22.More than $214.3 million to boost NSW Ambulance services, including:$126 million over four years to improve NSW Ambulance operations through a modern, integrated facility at Sydney Olympic Park;$54.3 million recurrent expenses over four years to enable NSW Ambulance to secure an improved mix of aircraft, including jet aircraft, to improve patient safety and access to emergency care;$34.0 million over four years to convert 246 paramedics to Intensive Care Paramedics, of which 80 per cent will be in regional New South Wales;Upgrade of in-ambulance defibrillators that improve electronic medical record integration capabilities between NSW Ambulance and hospital emergency departments across the state and especially in regional areas in 2021-22.$109.5 million over four years to develop 25 ‘Safeguards’ – Child and Adolescent Mental Health Crisis Teams across NSW to provide services to children and adolescents with moderate to severe mental health issues and their families/carers;$82.8 million over four years to continue strengthening specialist palliative and end of life care, including improving community-based care, enhancing hospital services, consumer support, the regional and rural workforce and providing state supported scholarships in palliative care medicine;$36.4 million over four years for 57 mental health Response and Recovery Specialists across regional and rural New South Wales to provide assertive outreach support for communities, and coordination with local services at the time of a disaster or crisis, and during the ongoing recovery phase;$21.6 million over four years to provide a state-wide Transcatheter Aortic Valve Implementation (TAVI) service for high risk can you buy viagra over the counter patients, including those in rural and remote areas of NSW;$12.2 million over two years to fund Tresillian for six Regional Family Care Centres as well as five ‘Tresillian 2U vans’ and staffing for the Macksville residential unit;$8.6 million over four years to support community care for people with movement disorders, such as Parkinson’s Disease by delivering specialist nurses and allied health staff in 15 Local Health Districts.

This package also includes funding for Parkinson’s NSW to can you buy viagra over the counter support their InfoLine service as well as additional teaching, training and capacity building;$7.7 million over four years to pilot a new model of care for children and young people with behavioural disorders including Attention Deficit Hyperactivity Disorder (ADHD) in two regional Local Health Districts;$3.0 million towards the establishment of ACON’s LGBTQ+ health centre to improve access to primary and community-based healthcare.NSW Health will invest $10.8 billion on capital infrastructure over the next four years with a program of $3.2 billion in 2021-22. This record investment will ensure the 29 new and upgraded hospitals and health facilities announced prior to the 2019 state election will can you buy viagra over the counter commence before March 2023. The funding also includes:$327 million for new works commencing in 2021-22 including nine hospital upgrades or redevelopments, two major Information Communication Technology projects, establishment of a HealthOne at Canowindra, and a number of NSW Ambulance related projects;Hospital upgrades and redevelopments including:$45 million for the Muswellbrook Hospital Stage 3 Redevelopment;an additional $50 million for the Sydney Children’s Hospitals Network at Randwickan additional $15 million for Goulburn Hospital and commencement of the Ryde, Rouse Hill, Moree, Gunnedah, and Wentworth Hospital RedevelopmentsThis investment also includes funding in 2021-22 to progress the $10 million NSW paediatric cardiac enhancements across the Sydney Children’s Hospitals Network.Of this record investment, almost $2.5 billion will be allocated across the State to continue Health’s record can you buy viagra over the counter capital program which includes 37 hospital upgrades or redevelopments (with four new hospitals) and eight regional and metropolitan car parks currently being built. In addition, the 2021-22 Budget includes $280.2 million for Information Communication Technology projects, $80 million for the asset refurbishment and replacement program and $109 million for works funded by local health districts and specialty health networks through the Locally Funded Initiatives Program.Hospital upgrades and redevelopments in progress include:Bankstown and Lidcombe Hospital ($1.3 billion)Nepean Hospital ($1.0 billion)John Hunter Hospital and car park ($835 million)Randwick Campus ($783 million)Royal Prince Alfred Hospital ($750 million)Liverpool Health and Academic Precinct, can you buy viagra over the counter including carpark ($790 million)The new Shellharbour Hospital and Integrated Services ($699 million)Tweed Hospital ($673 million)Campbelltown Hospital ($632 million)Children’s Hospital Westmead Stage 2 ($619 million)Sydney Children’s Hospital Randwick ($608 million)The new Maitland Hospital ($470 million)Shoalhaven Hospital ($438 million)Wagga Wagga Hospital ($431 million)St George Hospital ($385 million)Concord Hospital ($341 million)Lismore Base Hospital ($313 million)Dubbo Health Service ($306 million) andGriffith Base Hospital ($250 million).

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Google Cloud pulled back the curtain yesterday on two artificial intelligence tools designed to help healthcare and life science online pharmacy viagra organizations scan and analyze large volumes of unstructured text, the Healthcare Natural Language API and AutoML Entity Extraction for Healthcare.The first of these two offerings looks to automatically extract common trends or other insights from medical records notes http://biogreen-tech.com/?page_id=43 or other digital text that would normally require time-intensive manual review. According to the company, the machine online pharmacy viagra learning tool discerns clinically relevant information based on the context of surrounding language, allowing the technology to, for instance, distinguish between past and newly prescribed medications.The Healthcare Natural Language API can be deployed within a provider organization for analysis, or can be implemented within a range of health applications that support unstructured text, Google said. Potential use cases supplied by the company in a blog post include a telehealth app that stores transcribed conversations between the doctor and a patient, as well as clinical trials enrolling patients based on specific inclusion or exclusion criteria,AutoML Entity Extraction for Healthcare, meanwhile, seeks to lower the barrier to AI text data analysis for healthcare workers. According to the company, it provides an easier-to-use interface that helps less experienced users train online pharmacy viagra their own machine learning analysis models.

It has, for example, a tool that extracts information on patients' relevant gene mutations, or on socioeconomic factors.Google launched both tools yesterday in public preview. The Healthcare Natural Language API is available to enterprises for online pharmacy viagra free until Dec. 10, while AutoML Entity Extraction for Healthcare is free for the first 5,000 text records and 1,000 document pages imported.WHY IT MATTERSUnstructured data housed within EHRs or other medical notations house a wealth of relevant patient data that could be used for clinical research, accurate clinical modeling or streamlining other administrative tasks. However, the large volume of data organizations generate each day would require a substantial online pharmacy viagra effort to record and analyze by hand."For healthcare professionals, the process of reviewing and writing medical documents is incredibly labor-intensive," Andreea Bodnari, a product manager at Google Cloud, wrote in the blog post announcement.

"And the lack of intelligent, easy-to-use tools to assist with the unique requirements of medical documentation creates data capturing errors, a diminished patient-doctor experience, and physician burnout."Google Cloud's tools are the latest seeking to address the longstanding challenge of unstructured data, and notably seek to do so with guided interfaces and other considerations that make these analyses more accessible to healthcare staff.THE LARGER TRENDGoogle isn't the only major tech player that's aware of natural language processing's potential in healthcare. Its chief rival, Amazon Web Services, launched its own tool called Amazon Comprehend Medical near the tail-end of 2018, and similarly highlighted online pharmacy viagra the ease with which the machine learning tool could be deployed within an enterprise's existing systems.There's certainly interest among healthcare organizations for this type of technology. Just this week, Centene announced plans to purchase the patient data analytics platform Apixio in order to deploy similar text-analysis technology across its managed care enterprise.In response to the erectile dysfunction treatment viagra, Vodafone has released a report on the potential of 5G and Internet of Things (IoT) technology in health and social care.Better Health, Connected Health. How 5G and IoT Technology can Transform Health and Social Care found overwhelming support for the introduction and increase of digital online pharmacy viagra technologies in the NHS, including 5G and IoT, as a way of streamlining healthcare and making it more affordable.This could pave the way for smart buildings, which would be greener and save the NHS money.

5G-connected ambulances that link paramedics and clinicians to treat patients faster and more effectively. And even the roll-out of remote assisted surgery and training, saving time and potentially elevating the quality of care.WHY IT MATTERSThe findings of the research identified that 57% of those online pharmacy viagra surveyed would be comfortable continuing to conduct some of their medical appointments over video after the viagra is over, which equates to a demand for quality internet connectivity for NHS staff and patients alike.It also found that 75% of respondents believed the government should invest in digital technology for the NHS, in order to future-proof the UK health sector. This was matched by 71% who believed that the 40 new hospitals promised by the government by 2030 should be equipped with the latest digital technology.In response to these results, the report laid out a series of government recommendations, including NHS estate upgrade and innovation, including in care homes to tackle loneliness. Increased social online pharmacy viagra and technological prescribing to treat long-term conditions.

Investment in 5G connected ambulances and delivery drones online pharmacy viagra. And financial support for devices compliant with NHS digital services for those on low incomes.THE LARGER PICTUREIn July of last year, Vodafone launched its 5G network in seven UK cities, not just improving access to telemedicine and virtual reality training but also enabling remote surgery. This move online pharmacy viagra was recommended across the pond by AT&T who stressed the importance of 5G and IoT tech in a HIMSS Digital presentation.The report was published shortly after NHS Digital signed a deal to implement a new FHIR-compliant terminology system to improve data sharing.Vodafone was also one of many telecommunications companies to offer increased support to the NHS towards the beginning of the erectile dysfunction treatment viagra.ON THE RECORD“The possibilities unleashed by 5G and IoT touch almost every part of the healthcare system, from the visible (remote surgery, or drones carrying transplant organs and drugs between hospitals) to the unseen but vital (IoT-enabled hospital equipment management systems that use sensors to automatically monitor stock levels),” says Anne Sheehan, the business director of Vodafone UK.“This technology is already available and the NHS should take advantage of it now. We have a perfect opportunity to ensure that digital technology is designed in from the start, so that the hospitals of the future can use the technology of the future.”Professor Shafi Ahmed, CMO of Medical Realities and Connected Health Ambassador for Vodafone, told Healthcare IT News.

€œWhat the UK patient population has experienced in the last nine months is online pharmacy viagra different kind of health service that’s more flexible. For the patients themselves, it’s much more immediate and accessible and patients are far more [digitally] advanced than we expected. It has changed people’s perceptions about how health can be accessed and what they’re expecting from the health service."When asked about practical next online pharmacy viagra steps, Ahmed responded. €œIt’s about putting the right stakeholders together – academic institutions, policy-makers in government and industry leaders – and asking things like ‘what does [NHS digital innovation] look like?.

What are the online pharmacy viagra barriers to digital transformation?. €™ It’s about collaboration of all those parties that want change, that want to improve the healthcare of the nation.”Patients filed class-action complaints against the Mayo Clinic this past week. They are accusing the system of online pharmacy viagra violating the Minnesota Health Records Act. Mayo Clinic said in a news release in October that a former employee had inappropriately accessed the health records of more than 1,600 patients.

Now, multiple patients are seeking to have a class-action case declared against the clinic.According to a complaint filed last week in Olmsted County District Court, online pharmacy viagra Mayo Clinic told plaintiff Olga Ryabchuk that the potentially accessible data included her name, demographic information, birth date, medical record number and clinical notes. HIMSS20 Digital Learn on-demand, earn credit, find products and solutions. Get Started >> online pharmacy viagra. Mayo Clinic also said that images of "private parts" of Ryabchuk's body had been accessed, the suit online pharmacy viagra said.

"This is particularly troublesome because it's pretty intimate photographs of people," said Ryabchuk's lawyer, Marshall Tanick, in an interview with Healthcare IT News. Situations like these, said Tanick, "cry out for better controls [over] who has access online pharmacy viagra to this data." An additional complaint filed in Olmsted County District Court also seeks class-action status. Plaintiffs in that suit, Amanda Bloxton-Kippola and Chelsea Turner, said the breach included "nude photographs taken by Mayo Clinic in connection with the health care Plaintiffs received from Mayo Clinic," according to reporting from KROC.Mayo Clinic representatives said that the system does not comment on pending litigation. WHY IT MATTERS Ryabchuk is alleging a violation of the Minnesota Health Records Act, which forbids accessing a record locator or patient information service without authorization.She is also accusing the Mayo Clinic, and the resident in question, of online pharmacy viagra a common law invasion of privacy and negligent infliction of emotional distress.

Ryabchuk "was extremely distraught to learn of this unlawful access of her health records," read the complaint. "She was told that Mayo Clinic did a full investigation and interviewed the former employee and came to the decision that he was in [Ryabchuk's] medical chart with no business reason." In online pharmacy viagra addition to asking for a class certification, Ryabchuk's suit seeks damages in excess of $50,000 for her and other class members. Tanick, a Minneapolis-based lawyer, told Healthcare IT News that he's seen an increase in cases involving unauthorized record access."Some of them are external hacking, but many of them are internal employees snooping into medical records," he said. "I think it's because online pharmacy viagra these records are relatively easily accessible to internal people if there's not appropriate control on access," he added.

THE LARGER TREND As Tanick said, hospitals have faced increasing threats to patient data from external sources, such as hackers. But snooping employees online pharmacy viagra have presented problems too. In January 2015, nearly 850 patients were notified after an EHR audit that a pharmacist employee had been inappropriately accessing their medical data. Sometimes it's not the employees themselves online pharmacy viagra doing the snooping, but those who take advantage of security gaps.

In 2018, West Virginia-based Coplin Health Systems notified 43,000 patients of a potential data breach due to the theft of a laptop from an employee’s car.Though the laptop was password-protected, the data on it was unencrypted. ON THE RECORD "I think this is a significant case because of the online pharmacy viagra breadth of the access," said Tanick. "And of course, Mayo is a leading facility, so I think how this plays out could affect other cases." Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail.

Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.At the onset of erectile dysfunction treatment, COPE Community Services, a Tucson, Arizona-based nonprofit behavioral and physical healthcare organization serving more than 15,000 clients in Pima County, was unprepared to have its staff work remotely.THE PROBLEMCOPE needed to react quickly to the sudden change in the healthcare service delivery model and minimize any negative impact from these changes. Medicaid instituted new guidelines and procedure codes to address this new reality, but the turnaround time to implement these changes was very short.These obstacles had the potential to negatively affect COPE’s service delivery and balance sheet, so they needed to be addressed immediately. What COPE was experiencing had become a common setback with sobering consequences.In April 2020, the National Council for Behavioral Health discovered through its survey of 880 U.S. Healthcare organizations that nearly two-thirds of respondents reported being unable to survive for longer than three months under erectile dysfunction treatment conditions.

Additionally, almost half of all behavioral healthcare organizations already had cut staff.Because the prognosis was so grim, COPE knew it needed to act fast to minimize damage to the organization.PROPOSALTo keep staff operational, meet remotely with patients and maintain the functionality of the organization, COPE turned to Health Information Management Systems (HiMS, no relation to HIMSS, parent company of Healthcare IT News) for a rapid-response solution that included both hardware and software implementation.COPE CEO Rod Cook met with Khalid Al-Maskari, the CEO of HiMS, to create an add-on to COPE’s existing business continuity plan. As a longtime client of HiMS, COPE knew it could rely on the company to deliver the right solution to its 450 staff members and 15,000 patients, Cook said."The value of disaster-preparedness, coupled with and an in-depth business continuity plan, should not be understated for integrated healthcare organizations."Rod Cook, COPE Community ServicesTogether, they developed a plan to address three areas. Remote workforce, revenue cycle management continuity and a new telemedicine solution. To deliver a solution on such a tight turnaround would be difficult, Cook said, but COPE and HiMS knew that moving quickly would be the difference between struggling and thriving during a time of crisis.“Instead of having COPE use desktop computers, HiMS suggested laptops and VPN access to see patients at home,” Cook explained.

€œHiMS had a few laptops in stock, but the company needed to purchase 50 laptops to meet COPE’s needs. During a time when supply chains were disrupted, HiMS leveraged its close relationship with one of its vendors.“In just three days, the company had 50 laptops delivered to COPE,” he added. €œBecause HiMS already had the software in place to make device deployment easy, it took just three days total for shipping, inventory, software downloads, creating VPN access and deploying to staff.”MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions.

To read this special report, click here.MEETING THE CHALLENGEFirst, HiMS’s AXiOM EHR software needed to be updated with the latest HCPCS codes for certain erectile dysfunction treatment diagnostic tests, as well as CPT codes for testing purposes.COPE also needed a way to bill for services that weren’t provided via telehealth. Because AXiOM is entirely cloud-based, it was able to update COPE’s code modifiers remotely without issue, Cook said.“Within two days, AXiOM was updated with the codes that met state and federal requirements, and it was configured to easily work for remote staff without placing the burden of setup, connection and configuration on clinical teams,” Cook noted. €œZoom was then integrated into the software platform, allowing patients and clinicians to communicate with very little disruption.”HiMS’ IT department also conducted Zoom tutorials with clinicians to eliminate any possible learning curves, in addition to implementing additional security protocols to prevent Zoom hacking, he added.“COPE also benefited from its longstanding partnership with HiMS,” Cook said. €œThe clinics’ use of all of HiMS’ services made its transition to a virtual care model significantly faster than it would’ve been using multiple technology providers.

The reason for this is HiMS’ prioritization of interoperability.”Through AXiOM, all of COPE’s technologies, including telehealth and revenue cycle management (RCM), can communicate with each other. When a telehealth appointment ends, AXiOM enables COPE to collect that patient data and bill automatically without the risk of human error. This feature allowed COPE not to experience a revenue decrease during the viagra, Cook noted.“HiMS also created a new website to accept online enrollments for COPE,” he said. €œThis solution ensured continuity and helped alleviate the viagra-related stress staff members were experiencing.

Because AXiOM made it easy to connect, clinical teams were able to focus on quality of care.”RESULTSAs a result of the rapid response plan, services continued to be provided at a pre-viagra rate, and patients were seen with little disruption, Cook reported.“The online enrollment website also helped many clients connect directly with COPE for intake and evaluation,” he said. €œCOPE even experienced a greater influx of clients in 2020 than it had before erectile dysfunction treatment. Due to increased enrollment levels, COPE maintained a favorable financial position when several others were hemorrhaging patients and closing their doors.”Another success metric was the lack of learning curve for COPE’s staff, he added. All staff members had complete access to their files at home through VPN access, and no data was lost in the migration.

Having e-mail, Zoom and everything else preconfigured alleviated the transition burden.The only true difference from an IT perspective was the use of laptops instead of desktops. Everything clinical staff had pre-viagra was seamlessly transitioned from their in-person desktop to their work-from-home laptops.ADVICE FOR OTHERS“The value of disaster-preparedness, coupled with an in-depth business continuity plan, should not be understated for integrated healthcare organizations,” Cook advised. €œOrganizations should also look for an EHR that keeps the focus on its customers and understands the value of putting patients first. For those considering newer EHRs or other health-tech solutions for remote treatment and billing, interoperability should be a key consideration.”Data silos from incompatible software solutions can lead to major issues down the line, including data loss, slower revenue cycles and patient mismanagement, he added.“When providers choose solutions that are both interoperable with existing systems and user friendly for their staff, clinical team members can access relevant data from any of its systems without compromising accuracy,” he said.“In addition, administrators or clinical team members only need to input data once, making it easier for staff to communicate with each other and with their patients.

Interoperable systems with artificial intelligence can also ensure billing codes are entered properly, which helps to reduce the rate of claims denials.”Twitter. @SiwickiHealthITEmail the writer. Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication..

Google Cloud pulled back the curtain yesterday on two artificial intelligence tools designed to help healthcare and life science organizations scan and analyze large volumes of unstructured text, the Healthcare Natural Language API and can you buy viagra over the counter AutoML Entity Extraction for Healthcare.The first of these two offerings looks to automatically extract common trends or other insights from medical records notes or other digital http://biogreen-tech.com/?page_id=43 text that would normally require time-intensive manual review. According to the company, the machine learning tool discerns clinically relevant information based on the context of surrounding language, allowing the technology to, for instance, distinguish between past and newly prescribed can you buy viagra over the counter medications.The Healthcare Natural Language API can be deployed within a provider organization for analysis, or can be implemented within a range of health applications that support unstructured text, Google said. Potential use cases supplied by the company in a blog post include a telehealth app that stores transcribed conversations between the doctor and a patient, as well as clinical trials enrolling patients based on specific inclusion or exclusion criteria,AutoML Entity Extraction for Healthcare, meanwhile, seeks to lower the barrier to AI text data analysis for healthcare workers. According to the company, it provides an easier-to-use interface that helps less experienced can you buy viagra over the counter users train their own machine learning analysis models.

It has, for example, a tool that extracts information on patients' relevant gene mutations, or on socioeconomic factors.Google launched both tools yesterday in public preview. The Healthcare Natural Language API is available to enterprises can you buy viagra over the counter for free until Dec. 10, while AutoML Entity Extraction for Healthcare is free for the first 5,000 text records and 1,000 document pages imported.WHY IT MATTERSUnstructured data housed within EHRs or other medical notations house a wealth of relevant patient data that could be used for clinical research, accurate clinical modeling or streamlining other administrative tasks. However, the large volume of data organizations generate each day would require a substantial effort to record and analyze by hand."For can you buy viagra over the counter healthcare professionals, the process of reviewing and writing medical documents is incredibly labor-intensive," Andreea Bodnari, a product manager at Google Cloud, wrote in the blog post announcement.

"And the lack of intelligent, easy-to-use tools to assist with the unique requirements of medical documentation creates data capturing errors, a diminished patient-doctor experience, and physician burnout."Google Cloud's tools are the latest seeking to address the longstanding challenge of unstructured data, and notably seek to do so with guided interfaces and other considerations that make these analyses more accessible to healthcare staff.THE LARGER TRENDGoogle isn't the only major tech player that's aware of natural language processing's potential in healthcare. Its chief rival, Amazon Web Services, launched its own tool called Amazon can you buy viagra over the counter Comprehend Medical near the tail-end of 2018, and similarly highlighted the ease with which the machine learning tool could be deployed within an enterprise's existing systems.There's certainly interest among healthcare organizations for this type of technology. Just this week, Centene announced plans to purchase the patient data analytics platform Apixio in order to deploy similar text-analysis technology across its managed care enterprise.In response to the erectile dysfunction treatment viagra, Vodafone has released a report on the potential of 5G and Internet of Things (IoT) technology in health and social care.Better Health, Connected Health. How 5G and IoT can you buy viagra over the counter Technology can Transform Health and Social Care found overwhelming support for the introduction and increase of digital technologies in the NHS, including 5G and IoT, as a way of streamlining healthcare and making it more affordable.This could pave the way for smart buildings, which would be greener and save the NHS money.

5G-connected ambulances that link paramedics and clinicians to treat patients faster and more effectively. And even the roll-out of remote assisted surgery can you buy viagra over the counter and training, saving time and potentially elevating the quality of care.WHY IT MATTERSThe findings of the research identified that 57% of those surveyed would be comfortable continuing to conduct some of their medical appointments over video after the viagra is over, which equates to a demand for quality internet connectivity for NHS staff and patients alike.It also found that 75% of respondents believed the government should invest in digital technology for the NHS, in order to future-proof the UK health sector. This was matched by 71% who believed that the 40 new hospitals promised by the government by 2030 should be equipped with the latest digital technology.In response to these results, the report laid out a series of government recommendations, including NHS estate upgrade and innovation, including in care homes to tackle loneliness. Increased social and technological prescribing to treat long-term can you buy viagra over the counter conditions.

Investment in can you buy viagra over the counter 5G connected ambulances and delivery drones. And financial support for devices compliant with NHS digital services for those on low incomes.THE LARGER PICTUREIn July of last year, Vodafone launched its 5G network in seven UK cities, not just improving access to telemedicine and virtual reality training but also enabling remote surgery. This move was recommended across the pond by AT&T who stressed the importance of 5G and IoT tech in a HIMSS Digital presentation.The report was published shortly after NHS Digital signed a deal to implement a new FHIR-compliant terminology system to improve data sharing.Vodafone was also one of many telecommunications companies to offer increased support to the NHS towards the beginning of the erectile dysfunction treatment viagra.ON THE RECORD“The possibilities unleashed by 5G and IoT touch almost every part of the can you buy viagra over the counter healthcare system, from the visible (remote surgery, or drones carrying transplant organs and drugs between hospitals) to the unseen but vital (IoT-enabled hospital equipment management systems that use sensors to automatically monitor stock levels),” says Anne Sheehan, the business director of Vodafone UK.“This technology is already available and the NHS should take advantage of it now. We have a perfect opportunity to ensure that digital technology is designed in from the start, so that the hospitals of the future can use the technology of the future.”Professor Shafi Ahmed, CMO of Medical Realities and Connected Health Ambassador for Vodafone, told Healthcare IT News.

€œWhat the UK patient population has experienced in the last nine months is different kind of health can you buy viagra over the counter service that’s more flexible. For the patients themselves, it’s much more immediate and accessible and patients are far more [digitally] advanced than we expected. It has changed people’s perceptions about how health can be accessed and what can you buy viagra over the counter they’re expecting from the health service."When asked about practical next steps, Ahmed responded. €œIt’s about putting the right stakeholders together – academic institutions, policy-makers in government and industry leaders – and asking things like ‘what does [NHS digital innovation] look like?.

What are can you buy viagra over the counter the barriers to digital transformation?. €™ It’s about collaboration of all those parties that want change, that want to improve the healthcare of the nation.”Patients filed class-action complaints against the Mayo Clinic this past week. They are accusing the system can you buy viagra over the counter of violating the Minnesota Health Records Act. Mayo Clinic said in a news release in October that a former employee had inappropriately accessed the health records of more than 1,600 patients.

Now, multiple patients are seeking to have a class-action case declared against the clinic.According to a complaint filed last week in Olmsted County District Court, Mayo Clinic told plaintiff Olga Ryabchuk that the potentially accessible data included her name, demographic information, birth can you buy viagra over the counter date, medical record number and clinical notes. HIMSS20 Digital Learn on-demand, earn credit, find products and solutions. Get Started >> can you buy viagra over the counter. Mayo Clinic also can you buy viagra over the counter said that images of "private parts" of Ryabchuk's body had been accessed, the suit said.

"This is particularly troublesome because it's pretty intimate photographs of people," said Ryabchuk's lawyer, Marshall Tanick, in an interview with Healthcare IT News. Situations like these, said Tanick, "cry out can you buy viagra over the counter for better controls [over] who has access to this data." An additional complaint filed in Olmsted County District Court also seeks class-action status. Plaintiffs in that suit, Amanda Bloxton-Kippola and Chelsea Turner, said the breach included "nude photographs taken by Mayo Clinic in connection with the health care Plaintiffs received from Mayo Clinic," according to reporting from KROC.Mayo Clinic representatives said that the system does not comment on pending litigation. WHY IT MATTERS Ryabchuk is alleging a violation of the Minnesota Health Records Act, which forbids accessing a can you buy viagra over the counter record locator or patient information service without authorization.She is also accusing the Mayo Clinic, and the resident in question, of a common law invasion of privacy and negligent infliction of emotional distress.

Ryabchuk "was extremely distraught to learn of this unlawful access of her health records," read the complaint. "She was told that Mayo Clinic did a full investigation and interviewed the former employee and came to the decision that he was in [Ryabchuk's] medical chart with no business reason." In addition to asking for a class certification, Ryabchuk's suit seeks damages can you buy viagra over the counter in excess of $50,000 for her and other class members. Tanick, a Minneapolis-based lawyer, told Healthcare IT News that he's seen an increase in cases involving unauthorized record access."Some of them are external hacking, but many of them are internal employees snooping into medical records," he said. "I think it's because these records are relatively can you buy viagra over the counter easily accessible to internal people if there's not appropriate control news on access," he added.

THE LARGER TREND As Tanick said, hospitals have faced increasing threats to patient data from external sources, such as hackers. But snooping employees have presented problems can you buy viagra over the counter too. In January 2015, nearly 850 patients were notified after an EHR audit that a pharmacist employee had been inappropriately accessing their medical data. Sometimes can you buy viagra over the counter it's not the employees themselves doing the snooping, but those who take advantage of security gaps.

In 2018, West Virginia-based Coplin Health Systems notified 43,000 patients of a potential data breach due to the theft of a laptop from an employee’s car.Though the laptop was password-protected, the data on it was unencrypted. ON THE RECORD "I think this is a significant case because can you buy viagra over the counter of the breadth of the access," said Tanick. "And of course, Mayo is a leading facility, so I think how this plays out could affect other cases." Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail.

Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.At the onset of erectile dysfunction treatment, COPE Community Services, a Tucson, Arizona-based nonprofit behavioral and physical healthcare organization serving more than 15,000 clients in Pima County, was unprepared to have its staff work remotely.THE PROBLEMCOPE needed to react quickly to the sudden change in the healthcare service delivery model and minimize any negative impact from these changes. Medicaid instituted new guidelines and procedure codes to address this new reality, but the turnaround time to implement these changes was very short.These obstacles had the potential to negatively affect COPE’s service delivery and balance sheet, so they needed to be addressed immediately. What COPE was experiencing had become a common setback with sobering consequences.In April 2020, the National Council for Behavioral Health discovered through its survey of 880 U.S. Healthcare organizations that nearly two-thirds of respondents reported being unable to survive for longer than three months under erectile dysfunction treatment conditions.

Additionally, almost half of all behavioral healthcare organizations already had cut staff.Because the prognosis was so grim, COPE knew it needed to act fast to minimize damage to the organization.PROPOSALTo keep staff operational, meet remotely with patients and maintain the functionality of the organization, COPE turned to Health Information Management Systems (HiMS, no relation to HIMSS, parent company of Healthcare IT News) for a rapid-response solution that included both hardware and software implementation.COPE CEO Rod Cook met with Khalid Al-Maskari, the CEO of HiMS, to create an add-on to COPE’s existing business continuity plan. As a longtime client of HiMS, COPE knew it could rely on the company to deliver the right solution to its 450 staff members and 15,000 patients, Cook said."The value of disaster-preparedness, coupled with and an in-depth business continuity plan, should not be understated for integrated healthcare organizations."Rod Cook, COPE Community ServicesTogether, they developed a plan to address three areas. Remote workforce, revenue cycle management continuity and a new telemedicine solution. To deliver a solution on such a tight turnaround would be difficult, Cook said, but COPE and HiMS knew that moving quickly would be the difference between struggling and thriving during a time of crisis.“Instead of having COPE use desktop computers, HiMS suggested laptops and VPN access to see patients at home,” Cook explained.

€œHiMS had a few laptops in stock, but the company needed to purchase 50 laptops to meet COPE’s needs. During a time when supply chains were disrupted, HiMS leveraged its close relationship with one of its vendors.“In just three days, the company had 50 laptops delivered to COPE,” he added. €œBecause HiMS already had the software in place to make device deployment easy, it took just three days total for shipping, inventory, software downloads, creating VPN access and deploying to staff.”MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions.

To read this special report, click here.MEETING THE CHALLENGEFirst, HiMS’s AXiOM EHR software needed to be updated with the latest HCPCS codes for certain erectile dysfunction treatment diagnostic tests, as well as CPT codes for testing purposes.COPE also needed a way to bill for services that weren’t provided via telehealth. Because AXiOM is entirely cloud-based, it was able to update COPE’s code modifiers remotely without issue, Cook said.“Within two days, AXiOM was updated with the codes that met state and federal requirements, and it was configured to easily work for remote staff without placing the burden of setup, connection and configuration on clinical teams,” Cook noted. €œZoom was then integrated into the software platform, allowing patients and clinicians to communicate with very little disruption.”HiMS’ IT department also conducted Zoom tutorials with clinicians to eliminate any possible learning curves, in addition to implementing additional security protocols to prevent Zoom hacking, he added.“COPE also benefited from its longstanding partnership with HiMS,” Cook said. €œThe clinics’ use of all of HiMS’ services made its transition to a virtual care model significantly faster than it would’ve been using multiple technology providers.

The reason for this is HiMS’ prioritization of interoperability.”Through AXiOM, all of COPE’s technologies, including telehealth and revenue cycle management (RCM), can communicate with each other. When a telehealth appointment ends, AXiOM enables COPE to collect that patient data and bill automatically without the risk of human error. This feature allowed COPE not to experience a revenue decrease during the viagra, Cook noted.“HiMS also created a new website to accept online enrollments for COPE,” he said. €œThis solution ensured continuity and helped alleviate the viagra-related stress staff members were experiencing.

Because AXiOM made it easy to connect, clinical teams were able to focus on quality of care.”RESULTSAs a result of the rapid response plan, services continued to be provided at a pre-viagra rate, and patients were seen with little disruption, Cook reported.“The online enrollment website also helped many clients connect directly with COPE for intake and evaluation,” he said. €œCOPE even experienced a greater influx of clients in 2020 than it had before erectile dysfunction treatment. Due to increased enrollment levels, COPE maintained a favorable financial position when several others were hemorrhaging patients and closing their doors.”Another success metric was the lack of learning curve for COPE’s staff, he added. All staff members had complete access to their files at home through VPN access, and no data was lost in the migration.

Having e-mail, Zoom and everything else preconfigured alleviated the transition burden.The only true difference from an IT perspective was the use of laptops instead of desktops. Everything clinical staff had pre-viagra was seamlessly transitioned from their in-person desktop to their work-from-home laptops.ADVICE FOR OTHERS“The value of disaster-preparedness, coupled with an in-depth business continuity plan, should not be understated for integrated healthcare organizations,” Cook advised. €œOrganizations should also look for an EHR that keeps the focus on its customers and understands the value of putting patients first. For those considering newer EHRs or other health-tech solutions for remote treatment and billing, interoperability should be a key consideration.”Data silos from incompatible software solutions can lead to major issues down the line, including data loss, slower revenue cycles and patient mismanagement, he added.“When providers choose solutions that are both interoperable with existing systems and user friendly for their staff, clinical team members can access relevant data from any of its systems without compromising accuracy,” he said.“In addition, administrators or clinical team members only need to input data once, making it easier for staff to communicate with each other and with their patients.

Interoperable systems with artificial intelligence can also ensure billing codes are entered properly, which helps to reduce the rate of claims denials.”Twitter. @SiwickiHealthITEmail the writer. Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication..

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Key takeaways Medicaid expansion in Illinois Federalpoverty levelcalculator 0.0% comprar viagra of Federal Poverty Level Medicaid is an important part of overall health insurance enrollment and coverage in Illinois, with Medicaid and CHIP covering about article 20 percent of the state’s 12.5 million residents. About 20 percent of those covered are eligible for Medicaid due to the state’s expansion of Medicaid under the Affordable Care comprar viagra Act (ACA). The Illinois Department of Healthcare and Family Services maintains a running update of total enrollment numbers. As of April 2020, there were 607,408 Illinois residents comprar viagra covered under expanded Medicaid.

Enrollment under Medicaid expansion grew quickly in the early years after the eligibility guidelines were expanded, but enrollment was lower in 2020 than it was in 2016 (as of July 2016, Medicaid expansion enrollment stood at about 644,000 people).Total Medicaid enrollment includes people who are eligible under the ACA’s expansion of Medicaid to low-income adults, as well as people who were already in one of the traditional Medicaid groups (low-income pregnant women, children, parents of minor children, and aged, blind, or disabled residents. Most Illinois Medicaid enrollees comprar viagra are in one of those traditional eligibility groups, although enrollment in those groups has declined while enrollment in expanded Medicaid has grown. The expansion of Medicaid resulted in a net increase of more than 486,000 people in the Medicaid program in the first three years after expansion was implemented, although net enrollment growth had dropped to about 300,000 as of 2018. As of May 2020 (when the impact of job losses due to the erectile dysfunction treatment viagra were already starting comprar viagra to be seen), Total Medicaid enrollment in Illinois stood at about 2.96 million people — up from 2.62 million in 2013.Far more Illinois residents have enrolled in expanded Medicaid than the state expected.

Although that means the state is receiving more federal Medicaid funding than projected, it also means Illinois has to pay more than projected, as the state is paying 6 percent of the cost to cover the newly-eligible population in 2018, and that will grow to 10 percent in 2020 and future years. But the state’s uninsured rate has dropped from 12.7 percent in 2013 to 6.8 percent in 2017 (it had been even lower in 2016, at 6.5 percent, but it crept up a little, nationwide, comprar viagra in 2017). And the state has also seen a sharp reduction in the number of emergency room visits by uninsured patients.Medicaid funding for enhanced mental health careIn September 2016, Illinois officials requested permission from the federal government to use existing Medicaid funds (with no changes to eligibility or funding) to test different approaches to treating Medicaid enrollees who need mental health and/or substance abuse treatment. The state had planned to implement the changes in July 2017, but CMS didn’t approve the waiver proposal comprar viagra until May 2018.The idea is to focus more on preventive care, supportive housing services, and community-based care, rather than institutional care.

The state notes that while 25 percent of Illinois Medicaid enrollees have mental health and/or substance abuse diagnoses, their treatment accounts for 56 percent of the Medicaid program’s total cost.Under the terms of the approved waiver, Illinois is running ten pilot projects that provide coverage for services that weren’t previously covered by Medicaid, including short-term inpatient substance abuse treatment, services to help people manage withdrawals during substance abuse recovery, home health visits for new babies and for children born to opioid-addicted mothers, and job coaching and transportation services designed to help people obtain and keep employment.Hepatitis C drug coverage expanded in stages, now available to anyone with the diseaseIn the past few years, drugs that can cure Hepatitis C have burst onto the medical scene, heralded as miracles. But they can also be a strain on budgets, as the pill comprar viagra initially could cost more than $1,000 per day, and the treatment course lasts 12 weeks. Medicaid programs across the country have been grappled with how to handle the situation, and Illinois announced in September 2016 that they would loosen their guidelines in terms of when Hepatitis C drugs would be covered.Rather than restricting coverage only to the sickest patients, Illinois Medicaid began to cover Hepatitis C drugs for people with stage 3 and 4 liver scarring, rather than just 4. Advocates cheered the new rules, but cautioned that there was still no coverage for treatment in people with chronic Hepatitis C that hadn’t progressed as far as stage 3 liver scarring, and urged the state to continue to consider the issue.By 2018, the price of Hepatitis C medications had declined, and a generic version was set to hit the market in early 2019, priced at $24,000 for the comprar viagra full treatment course (as opposed to $90,000 in the early years that the drug was available).

And in October 2018, the state eliminated the restrictions on access to Hepatitis C drugs, allowing several thousand Illinois residents to obtain Hepatitis C medication through Medicaid, regardless of the stage of their disease and without having to prove sobriety.Who is eligible for Medicaid in Illinois?. Federal law specifies comprar viagra mandatory and optional coverage groups for Medicaid. States must cover the mandatory groups to receive federal Medicaid funding, and they qualify for additional funding if they cover optional groups.The federal government specifies minimum thresholds for eligibility for the various groups, and states can set their requirements at or above the minimum threshold. Illinois has established comprar viagra requirements that are near national averages.Illinois’ eligibility standards for Medicaid are:Children ages 0-18 qualify with family income levels up to 142 of the federal poverty level (FPL).

The Children’s Health Insurance Program covers children with family income up to 313 percent of FPLPregnant women qualify with family income up to 208 percent of FPLParents and other adults qualify with family income up to 133 percent of FPL (138 percent with the built-in 5 percent income disregard). How do I enroll in Medicaid in comprar viagra Illinois?. You have several options to enroll in Medicaid in Illinois:Apply online using the Illinois wesbite or Healthcare.gov.Apply in person and get help from the Department of Human Services (DHS). Find the nearest Family Community Resource Center.Apply by mail or fax, or apply online or call comprar viagra at 1-800-843-6154 (TTY 1-800-447-6404) and ask DHS to mail you an application.

Complete the application and mail or fax it back to the nearest Family Community Resource Center.Illinois Medicaid historyMedicaid was implemented in the state of Illinois in January 1966.Individuals covered by Medicaid in Illinois can choose either a fee-for-service plan or a managed care plan. The Illinois DHS site explains these options.Illinois has been slower than many other states in moving beneficiaries to managed comprar viagra care plans. However, the state did pass a law in 2011 that required expanding managed care to at least half the state’s Medicaid beneficiaries by Jan. 1, 2015 comprar viagra.

As of 2019, more than 81 percent of Illinois Medicaid enrollees were covered under Medicaid managed care plans.In June 2014, then-Governor Pat Quinn signed a Medicaid reform bill. The law restored adult dental care and podiatry services, aligns Illinois law with federal law to provide Medicaid coverage to children who have been without private insurance for three months, streamlines hospital and nursing-home reimbursement, and more.Illinois opted to expand Medicaid eligibility, as comprar viagra allowed by the ACA, in July 2013 for a January 1, 2014 effective date. Making Medicaid available to low-income, non-elderly adults is a key part of the Affordable Care Act’s strategy to reduce the nation’s uninsured rate. However, a Supreme Court ruling made Medicaid expansion optional, and as of mid-2020, there were still 12 states that had not expanded Medicaid (two others, Oklahoma and Missouri, had not yet expanded Medicaid but will do so in 2021, after voters approved Medicaid expansion ballot initiatives in 2020).The federal government paid 100 percent of the comprar viagra cost for the Medicaid expansion population through 2016.

After that, the federal government’s portion gradually decreased, reaching 90 percent by 2020, with Illinois covering the other 10 percent (it will remain at that level after 2020).At the time Medicaid expansion was approved, Illinois officials estimated that 342,000 Illinois residents would qualify. But according comprar viagra to the Chicago Tribune, about 350,000 new enrollees were approved in just the first several months, by June 2014. And a year later, by June 2015, total enrollments under Medicaid expansion in Illinois had reached 623,000. By August 2016, comprar viagra the total had exceeded 646,000.

But enrollment had dropped to 606,670 people as of July 2018, and remained at a very similar level (607,404) as of April 2020. That was still far higher than the state had initially projected, but comprar viagra lower than it had been a few years earlier.By May 2020, total enrollment in Medicaid and CHIP in Illinois stood at more than 2.9 million, and was 13 percent higher than it had been at the end of 2013. The total CHIP/Medicaid population includes people who were already enrolled in Medicaid pre-2014, people who were eligible but not yet enrolled at that point, and people who gained eligibility as a result of the ACA’s expansion of Medicaid.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces comprar viagra about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.At a glance. Medicare health insurance in Nevada Medicare enrollment in NevadaAs of mid-2020, there were 545,535 people enrolled in Medicare in Nevada, amounting to about 17 percent of the state’s population.[/hio_question] Most comprar viagra Americans become eligible for Medicare enrollment when they turn 65. But Medicare eligibility is also triggered for younger people if they’re disabled and have been receiving disability benefits for 24 months (people with ALS or end-stage renal disease do not have to wait 24 months for their Medicare coverage to begin). In Nevada, 13 percent of Medicare comprar viagra beneficiaries are under the age of 65 and eligible for Medicare due to a disability rather than age.

Nationwide, 15 percent of all Medicare beneficiaries — nearly 10 million people — are eligible due to disability. Medicare Advantage in NevadaIn most areas of the United States, private Medicare Advantage plans are available as an alternative to comprar viagra Original Medicare.In 2019, some of Nevada’s counties had no Medicare Advantage plans available for purchase (Nevada has 16 counties plus Carson City, and only nine of them had Medicare Advantage plans available in 2019). But all areas of Nevada have Medicare Advantage plans available in 2020, with the addition of Lasso Healthcare, comprar viagra which entered the market in Nevada with an MSA plan. Plan availability in 2020 ranges from just one plan (from Lasso Healthcare) in several counties, to 36 plans in Clark County.But the counties that didn’t have Advantage plans available prior to 2020 tend to have very low populations.

Despite the fact that nearly comprar viagra half of Nevada’s counties had no Medicare Advantage plans for sale, 35 percent of the state’s Medicare beneficiaries were enrolled in Medicare Advantage plans as of 2018 — compared with 34 percent nationwide. And by July 2020, the number of people enrolled in private Medicare plans in Nevada stood at 219,979 people, which was 40 percent of the state’s total Medicare coverage enrollment. The other 325,556 beneficiaries had comprar viagra Original Medicare. Between August 2019 and July 2020, Medicare Advantage enrollment in Nevada increased by 19,000 people, whereas Original Medicare enrollment decreased by nearly 7,000 people.People who enroll in Original Medicare get their coverage directly from the federal government, and have access to a nationwide network of providers.

But Original Medicare enrollees need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket comprar viagra costs.Original Medicare includes Medicare Part A (hospital inpatient services) and Part B (outpatient services). Medicare Advantage includes all of the benefits of Medicare Parts A and B, and the plans usually also have additional benefits, such as integrated Part D prescription drug coverage, dental and vision coverage, and extra programs like gym memberships and a 24-hour nurse hotline. But provider networks and service areas are limited with Medicare Advantage, and out-of-pocket costs (deductible, copays, and coinsurance) are often higher than they would be comprar viagra under Original Medicare plus a Medigap plan. There are pros and cons to either option, and no single solution that works for everyone.Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries opportunities to switch between Medicare Advantage enrollment and Original Medicare (and add, drop, or change to a different Medicare Part D prescription plan).

Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31 (only one plan change may be made during comprar viagra this window).Medigap in NevadaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. More than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those who don’t, Medigap plans (also known as Medicare supplement plans) will pay some or all of the out-of-pocket comprar viagra costs (deductible and coinsurance) they would otherwise have to pay if they had only Original Medicare.Medigap plans are sold by private insurance companies, but the plans are standardized under federal rules. There are ten different plan designs (differentiated by letters, A through N), and the benefits covered by a particular plan (Plan G, Plan K, etc.) are the same regardless of which insurer sells the plan.

This makes it easier for consumers to compare plans and make their choice based comprar viagra on factors such as price and customer service, knowing that the coverage will be the same regardless of which insurance company will provide the plan.32 insurance companies offer Medigap plans in Nevada as of 2020. Nearly all of them use attained age rating, which means that individual enrollees’ monthly premiums increase as they get older, regardless of how old they were when they purchased the policy. According to an AHIP analysis, 95,795 Nevada residents were enrolled in comprar viagra Medigap coverage as of 2018.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue.

This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a Medigap comprar viagra plan). It’s essential to purchase coverage in a timely fashion during this window. If you apply for a Medigap plan after it ends, the insurance companies are allowed to use medical underwriting to determine your eligibility for coverage and your monthly premium.People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least two years, or if they have ALS or end-stage comprar viagra renal disease. 13 percent of Nevada Medicare beneficiaries are under age 65.

But federal rules do not guarantee access comprar viagra to Medigap plans for people who are under 65. The majority of the states have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans, but Nevada is not one of them.Nevada does not require Medigap insurers to offer coverage to people under age 65. As of 2020, Nevada’s Medigap guide indicates that there is one insurer that offers Medigap Plan A to beneficiaries under the age of 65, but Medicare’s plan finder tool indicates that no insurers actually do so (in previous years, Transamerica Life Insurance Company offered Medigap Plan A to enrollees under 65 in Nevada—albeit at comprar viagra a higher premium—but that appears to no longer be the case). The Nevada Division of Insurance confirmed in 2018 that there are no other supplemental coverage options for under-65 Medicare enrollees (ie, no state-run high-risk pool or similar program).

But Medicare beneficiaries who are under age 65 do have the option to enroll in any available Medicare Advantage plan offered in comprar viagra their area, unless they have end-stage renal disease (as of 2021, people will be able to enroll in Medicare Advantage plans even if they have end-stage renal disease).Although there do not appear to be any Medigap plans available to people under 65 in Nevada, those individuals gain access to all of the available Medigap plans when they turn 65. At that point, they have the normal six-month open enrollment period for Medigap.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months of continuous coverage prior comprar viagra to your enrollment. And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium.

Nevada Medicare Part DOriginal Medicare does not provide comprar viagra coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries have supplemental medical coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare beneficiaries who do not have drug coverage through Medicaid or an employer’s insurance plan need to obtain Medicare Part D prescription coverage. It can comprar viagra be purchased as a stand-alone plan, or as part of a Medicare Advantage plan with integrated Medicare Part D enrollment.In 2020, there are 28 stand-alone Medicare Part D plans for sale in Nevada, with monthly premiums that range from about $13 to $84.As of mid-2020, there were 178,998 Medicare beneficiaries in Nevada (about a third of the state’s Medicare population) who were covered under stand-alone Medicare Part D plans. Another 210,606 had Part D prescription coverage integrated with their Medicare Advantage plans (this number has been increasing sharply as enrollment in Medicare Advantage plans has grown faster than overall Medicare enrollment in Nevada).Medicare Part D enrollment is available during the annual election period from October 15 to December 7.

You may change your comprar viagra mind more than once during this window. The last plan you pick will take effect January 1 of the coming year. Medicare spending comprar viagra in NevadaAverage per-beneficiary spending for Medicare in Nevada was $9,969 in 2018, based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for Medicare Advantage. Per-beneficiary Medicare spending in Nevada was slightly lower than the national average of $10,096 per enrollee.

Spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare in comprar viagra Nevada. Resources and information for Medicare beneficiaries and their caregiversNeed help with your Medicare application in Nevada?. Got questions about comprar viagra Medicare eligibility in Nevada?. You can contact the Nevada State Health Insurance Assistance Program with questions related to Medicare enrollment in Nevada.The Nevada Aging and Disability Services Division offers a variety of resources for Nevada Medicare beneficiaries.The Governor’s Office for Consumer Health Assistance (OCHA) is part of the Nevada Department of Health and Human Services, and can provide advice, guidance, and information on a variety of health-related issues.The Nevada Department of Health and Human Services website also has a resource page with information on programs available to help lower-income Medicare beneficiaries afford their coverage and healthcare.The Medicare Rights Center is a national resource that includes a website and a call center where consumers throughout the United States can get answers to a wide range of questions about Medicare.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions comprar viagra and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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Most Illinois Medicaid enrollees are in one of those traditional eligibility groups, although enrollment in can you buy viagra over the counter those groups has declined while enrollment in expanded Medicaid has grown. The expansion of Medicaid resulted in a net increase of more than 486,000 people in the Medicaid program in the first three years after expansion was implemented, although net enrollment growth had dropped to about 300,000 as of 2018. As of May 2020 (when the impact of job losses due to the erectile dysfunction treatment viagra were already starting to be seen), Total Medicaid enrollment in Illinois stood at about 2.96 million people — up from 2.62 million in 2013.Far more Illinois residents have can you buy viagra over the counter enrolled in expanded Medicaid than the state expected. Although that means the state is receiving more federal Medicaid funding than projected, it also means Illinois has to pay more than projected, as the state is paying 6 percent of the cost to cover the newly-eligible population in 2018, and that will grow to 10 percent in 2020 and future years. But the state’s uninsured rate has can you buy viagra over the counter dropped from 12.7 percent in 2013 to 6.8 percent in 2017 (it had been even lower in 2016, at 6.5 percent, but it crept up a little, nationwide, in 2017).

And the state has also seen a sharp reduction in the number of emergency room visits by uninsured patients.Medicaid funding for enhanced mental health careIn September 2016, Illinois officials requested permission from the federal government to use existing Medicaid funds (with no changes to eligibility or funding) to test different approaches to treating Medicaid enrollees who need mental health and/or substance abuse treatment. The state had planned to implement the changes in July 2017, but CMS can you buy viagra over the counter didn’t approve the waiver proposal until May 2018.The idea is to focus more on preventive care, supportive housing services, and community-based care, rather than institutional care. The state notes that while 25 percent of Illinois Medicaid enrollees have mental health and/or substance abuse diagnoses, their treatment accounts for 56 percent of the Medicaid program’s total cost.Under the terms of the approved waiver, Illinois is running ten pilot projects that provide coverage for services that weren’t previously covered by Medicaid, including short-term inpatient substance abuse treatment, services to help people manage withdrawals during substance abuse recovery, home health visits for new babies and for children born to opioid-addicted mothers, and job coaching and transportation services designed to help people obtain and keep employment.Hepatitis C drug coverage expanded in stages, now available to anyone with the diseaseIn the past few years, drugs that can cure Hepatitis C have burst onto the medical scene, heralded as miracles. But they can also be a strain on budgets, as the pill initially could cost more can you buy viagra over the counter than $1,000 per day, and the treatment course lasts 12 weeks. Medicaid programs across the country have been grappled with how to handle the situation, and Illinois announced in September 2016 that they would loosen their guidelines in terms of when Hepatitis C drugs would be covered.Rather than restricting coverage only to the sickest patients, Illinois Medicaid began to cover Hepatitis C drugs for people with stage 3 and 4 liver scarring, rather than just 4.

Advocates cheered the new rules, but cautioned that there was still no coverage for treatment in people with chronic Hepatitis C that hadn’t progressed as far as stage 3 liver scarring, and urged the state to continue to consider the issue.By 2018, the price of Hepatitis C medications had declined, and a generic version was set to hit the market in early 2019, priced at $24,000 for the full treatment can you buy viagra over the counter course (as opposed to $90,000 in the early years that the drug was available). And in October 2018, the state eliminated the restrictions on access to Hepatitis C drugs, allowing several thousand Illinois residents to obtain Hepatitis C medication through Medicaid, regardless of the stage of their disease and without having to prove sobriety.Who is eligible for Medicaid in Illinois?. Federal law specifies mandatory can you buy viagra over the counter and optional coverage groups for Medicaid. States must cover the mandatory groups to receive federal Medicaid funding, and they qualify for additional funding if they cover optional groups.The federal government specifies minimum thresholds for eligibility for the various groups, and states can set their requirements at or above the minimum threshold. Illinois has established requirements that are near national averages.Illinois’ eligibility standards for Medicaid are:Children ages 0-18 qualify with family income levels up to 142 can you buy viagra over the counter of the federal poverty level (FPL).

The Children’s Health Insurance Program covers children with family income up to 313 percent of FPLPregnant women qualify with family income up to 208 percent of FPLParents and other adults qualify with family income up to 133 percent of FPL (138 percent with the built-in 5 percent income disregard). How do I enroll in can you buy viagra over the counter Medicaid in Illinois?. You have several options to enroll in Medicaid in Illinois:Apply online using the Illinois wesbite or Healthcare.gov.Apply in person and get help from the Department of Human Services (DHS). Find the nearest Family Community Resource Center.Apply by mail or fax, or apply online or call at 1-800-843-6154 (TTY 1-800-447-6404) and ask DHS to can you buy viagra over the counter mail you an application. Complete the application and mail or fax it back to the nearest Family Community Resource Center.Illinois Medicaid historyMedicaid was implemented in the state of Illinois in January 1966.Individuals covered by Medicaid in Illinois can choose either a fee-for-service plan or a managed care plan.

The Illinois DHS site explains these can you buy viagra over the counter options.Illinois has been slower than many other states in moving beneficiaries to managed care plans. However, the state did pass a law in 2011 that required expanding managed care to at least half the state’s Medicaid beneficiaries by Jan. 1, 2015 can you buy viagra over the counter. As of 2019, more than 81 percent of Illinois Medicaid enrollees were covered under Medicaid managed care plans.In June 2014, then-Governor Pat Quinn signed a Medicaid reform bill. The law restored adult dental care and podiatry services, aligns Illinois law with federal law to provide Medicaid can you buy viagra over the counter coverage to children who have been without private insurance for three months, streamlines hospital and nursing-home reimbursement, and more.Illinois opted to expand Medicaid eligibility, as allowed by the ACA, in July 2013 for a January 1, 2014 effective date.

Making Medicaid available to low-income, non-elderly adults is a key part of the Affordable Care Act’s strategy to reduce the nation’s uninsured rate. However, a Supreme Court ruling made Medicaid expansion optional, and as of mid-2020, there were still 12 states can you buy viagra over the counter that had not expanded Medicaid (two others, Oklahoma and Missouri, had not yet expanded Medicaid but will do so in 2021, after voters approved Medicaid expansion ballot initiatives in 2020).The federal government paid 100 percent of the cost for the Medicaid expansion population through 2016. After that, the federal government’s portion gradually decreased, reaching 90 percent by 2020, with Illinois covering the other 10 percent (it will remain at that level after 2020).At the time Medicaid expansion was approved, Illinois officials estimated that 342,000 Illinois residents would qualify. But according can you buy viagra over the counter to the Chicago Tribune, about 350,000 new enrollees were approved in just the first several months, by June 2014. And a year later, by June 2015, total enrollments under Medicaid expansion in Illinois had reached 623,000.

By August 2016, the total had exceeded can you buy viagra over the counter 646,000. But enrollment had dropped to 606,670 people as of July 2018, and remained at a very similar level (607,404) as of April 2020. That was still far higher than the state had initially projected, but lower than it had been a few years earlier.By May 2020, total enrollment in Medicaid can you buy viagra over the counter and CHIP in Illinois stood at more than 2.9 million, and was 13 percent higher than it had been at the end of 2013. The total CHIP/Medicaid population includes people who were already enrolled in Medicaid pre-2014, people who were eligible but not yet enrolled at that point, and people who gained eligibility as a result of the ACA’s expansion of Medicaid.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has can you buy viagra over the counter written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.At a glance. Medicare health insurance in Nevada Medicare enrollment in NevadaAs of mid-2020, there were 545,535 people enrolled in Medicare in Nevada, amounting to about 17 percent of the state’s population.[/hio_question] Most Americans become eligible can you buy viagra over the counter for Medicare enrollment when they turn 65. But Medicare eligibility is also triggered for younger people if they’re disabled and have been receiving disability benefits for 24 months (people with ALS or end-stage renal disease do not have to wait 24 months for their Medicare coverage to begin). In Nevada, 13 percent of Medicare beneficiaries are under the age of 65 and eligible for Medicare due to can you buy viagra over the counter a disability rather than age. Nationwide, 15 percent of all Medicare beneficiaries — nearly 10 million people — are eligible due to disability.

Medicare Advantage in NevadaIn most areas of the United States, private Medicare Advantage plans are available can you buy viagra over the counter as an alternative to Original Medicare.In 2019, some of Nevada’s counties had no Medicare Advantage plans available for purchase (Nevada has 16 counties plus Carson City, and only nine of them had Medicare Advantage plans available in 2019). But all areas of Nevada have Medicare Advantage plans available in 2020, with the addition of Lasso Healthcare, which entered the market in can you buy viagra over the counter Nevada with an MSA plan. Plan availability in 2020 ranges from just one plan (from Lasso Healthcare) in several counties, to 36 plans in Clark County.But the counties that didn’t have Advantage plans available prior to 2020 tend to have very low populations. Despite the fact that nearly half of Nevada’s counties had no can you buy viagra over the counter Medicare Advantage plans for sale, 35 percent of the state’s Medicare beneficiaries were enrolled in Medicare Advantage plans as of 2018 — compared with 34 percent nationwide. And by July 2020, the number of people enrolled in private Medicare plans in Nevada stood at 219,979 people, which was 40 percent of the state’s total Medicare coverage enrollment.

The other 325,556 beneficiaries had Original Medicare can you buy viagra over the counter. Between August 2019 and July 2020, Medicare Advantage enrollment in Nevada increased by 19,000 people, whereas Original Medicare enrollment decreased by nearly 7,000 people.People who enroll in Original Medicare get their coverage directly from the federal government, and have access to a nationwide network of providers. But Original Medicare enrollees need supplemental coverage (from an employer-sponsored plan, Medicaid, or privately purchased plans) for things like prescription drugs and out-of-pocket costs.Original Medicare includes Medicare Part A can you buy viagra over the counter (hospital inpatient services) and Part B (outpatient services). Medicare Advantage includes all of the benefits of Medicare Parts A and B, and the plans usually also have additional benefits, such as integrated Part D prescription drug coverage, dental and vision coverage, and extra programs like gym memberships and a 24-hour nurse hotline. But provider networks and service areas are limited with Medicare Advantage, and out-of-pocket costs (deductible, copays, and coinsurance) are often higher than they would be under Original can you buy viagra over the counter Medicare plus a Medigap plan.

There are pros and cons to either option, and no single solution that works for everyone.Medicare’s annual election period (October 15 to December 7 each year) allows Medicare beneficiaries opportunities to switch between Medicare Advantage enrollment and Original Medicare (and add, drop, or change to a different Medicare Part D prescription plan). Medicare Advantage enrollees also have the option to switch to a different Advantage plan or to Original Medicare during the Medicare Advantage open enrollment period, which runs from January 1 to March 31 (only one plan can you buy viagra over the counter change may be made during this window).Medigap in NevadaOriginal Medicare does not limit out-of-pocket costs, so most enrollees maintain some form of supplemental coverage. More than half of Original Medicare beneficiaries get their supplemental coverage through an employer-sponsored plan or Medicaid. But for those can you buy viagra over the counter who don’t, Medigap plans (also known as Medicare supplement plans) will pay some or all of the out-of-pocket costs (deductible and coinsurance) they would otherwise have to pay if they had only Original Medicare.Medigap plans are sold by private insurance companies, but the plans are standardized under federal rules. There are ten different plan designs (differentiated by letters, A through N), and the benefits covered by a particular plan (Plan G, Plan K, etc.) are the same regardless of which insurer sells the plan.

This makes it easier for consumers to compare plans and make their choice based on factors such as price and customer service, knowing that the coverage will be the same regardless of which can you buy viagra over the counter insurance company will provide the plan.32 insurance companies offer Medigap plans in Nevada as of 2020. Nearly all of them use attained age rating, which means that individual enrollees’ monthly premiums increase as they get older, regardless of how old they were when they purchased the policy. According to an AHIP analysis, 95,795 Nevada residents were enrolled in Medigap coverage as of 2018.Unlike other private Medicare coverage (Medicare Advantage and Medicare Part D plans), there is no annual open enrollment can you buy viagra over the counter window for Medigap plans. Instead, federal rules provide a one-time six-month window when Medigap coverage is guaranteed-issue. This window starts when a person is at least 65 and enrolled in Medicare Part B (you must be enrolled in both Part A and Part B to buy a can you buy viagra over the counter Medigap plan).

It’s essential to purchase coverage in a timely fashion during this window. If you apply for a Medigap plan after it ends, the insurance companies are allowed to use medical underwriting to determine your eligibility for coverage and your monthly premium.People who aren’t yet 65 can enroll in Medicare if they’re disabled and have been receiving disability benefits for at least can you buy viagra over the counter two years, or if they have ALS or end-stage renal disease. 13 percent of Nevada Medicare beneficiaries are under age 65. But federal rules do can you buy viagra over the counter not guarantee access to Medigap plans for people who are under 65. The majority of the states have implemented rules to ensure that disabled Medicare beneficiaries have at least some access to Medigap plans, but Nevada is not one of them.Nevada does not require Medigap insurers to offer coverage to people under age 65.

As of 2020, Nevada’s Medigap guide indicates that there is one insurer that offers Medigap Plan A to beneficiaries under the age of 65, but Medicare’s plan finder tool indicates that no insurers actually can you buy viagra over the counter do so (in previous years, Transamerica Life Insurance Company offered Medigap Plan A to enrollees under 65 in Nevada—albeit at a higher premium—but that appears to no longer be the case). The Nevada Division of Insurance confirmed in 2018 that there are no other supplemental coverage options for under-65 Medicare enrollees (ie, no state-run high-risk pool or similar program). But Medicare beneficiaries who are under age 65 do have the option to enroll in any available Medicare Advantage plan offered in their area, unless they have end-stage renal disease (as of 2021, people will be able to enroll in Medicare Advantage plans even if they have end-stage renal disease).Although can you buy viagra over the counter there do not appear to be any Medigap plans available to people under 65 in Nevada, those individuals gain access to all of the available Medigap plans when they turn 65. At that point, they have the normal six-month open enrollment period for Medigap.Although the Affordable Care Act eliminated pre-existing condition exclusions in most of the private health insurance market, those rules don’t apply to Medigap plans. Medigap insurers can impose a pre-existing condition waiting period of up to six months if you didn’t have at least six months can you buy viagra over the counter of continuous coverage prior to your enrollment.

And if you apply for a Medigap plan after your initial enrollment window closes (assuming you aren’t eligible for one of the limited guaranteed-issue rights), the Medigap insurer can consider your medical history in determining whether to accept your application, and at what premium. Nevada Medicare Part DOriginal Medicare can you buy viagra over the counter does not provide coverage for outpatient prescription drugs. More than half of Original Medicare beneficiaries have supplemental medical coverage via an employer-sponsored plan (from a current or former employer or spouse’s employer) or Medicaid, and these plans often include prescription coverage.But Medicare beneficiaries who do not have drug coverage through Medicaid or an employer’s insurance plan need to obtain Medicare Part D prescription coverage. It can be purchased as a stand-alone plan, or as part of a Medicare Advantage plan with integrated Medicare Part D enrollment.In 2020, there are 28 stand-alone Medicare Part D plans for sale in Nevada, with monthly premiums that range from about $13 to $84.As of mid-2020, there were 178,998 Medicare beneficiaries in Nevada (about a third of the state’s Medicare population) who were covered under stand-alone Medicare Part can you buy viagra over the counter D plans. Another 210,606 had Part D prescription coverage integrated with their Medicare Advantage plans (this number has been increasing sharply as enrollment in Medicare Advantage plans has grown faster than overall Medicare enrollment in Nevada).Medicare Part D enrollment is available during the annual election period from October 15 to December 7.

You may change your mind more can you buy viagra over the counter than once during this window. The last plan you pick will take effect January 1 of the coming year. Medicare spending in NevadaAverage per-beneficiary spending for Medicare in Nevada was $9,969 in 2018, based on data that were standardized to eliminate regional differences in payment rates, and did not include costs for can you buy viagra over the counter Medicare Advantage. Per-beneficiary Medicare spending in Nevada was slightly lower than the national average of $10,096 per enrollee. Spending was highest in Louisiana, at $11,932, and lowest in Hawaii, at just $6,971.Medicare can you buy viagra over the counter in Nevada.

Resources and information for Medicare beneficiaries and their caregiversNeed help with your Medicare application in Nevada?. Got questions about Medicare eligibility in can you buy viagra over the counter Nevada?. You can contact the Nevada State Health Insurance Assistance Program with questions related to Medicare enrollment in Nevada.The Nevada Aging and Disability Services Division offers a variety of resources for Nevada Medicare beneficiaries.The Governor’s Office for Consumer Health Assistance (OCHA) is part of the Nevada Department of Health and Human Services, and can provide advice, guidance, and information on a variety of health-related issues.The Nevada Department of Health and Human Services website also has a resource page with information on programs available to help lower-income Medicare beneficiaries afford their coverage and healthcare.The Medicare Rights Center is a national resource that includes a website and a call center where consumers throughout the United States can get answers to a wide range of questions about Medicare.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act can you buy viagra over the counter for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to note that information and guidance about can you buy viagra over the counter erectile dysfunction treatment continually evolve as conditions change. Workers and employers are encouraged to regularly refer to the resources below for updates:This week I had the opportunity to host the U.S. Department of Labor’s Veterans’ Employment and Training Service HIRE Vets Medallion Awards Ceremony honoring the 675 awardees for 2020.

While we would have loved to recognize our recipients in person, we were glad to create a presentation that they could share with their employees, customers and prospective can you buy viagra over the counter employees. The HIRE Vets Medallion Award is the only federal-level veterans’ employment award that recognizes a company or organization’s commitment to veteran hiring, retention and professional development.If you missed out on the awards ceremony, you can watch it here. This year’s keynote address came from Sgt. Maj. Of the Army Micheal Grinston and included a motivating Army video!.

[embedded content] These 675 employers set an example for prioritizing and encouraging successful veteran hiring and retention. Search the list of the 2020 HIRE Vets Medallion Award recipients located across the United States to find the businesses that demonstrate an outstanding commitment to and proven success attracting and retaining veterans. For the employers, the medallion represents a trusted badge that transitioning service members and veterans can rely on when looking for their next job, which provides the awardees with increased access to this valuable talent pool. We welcome you to stop by our ceremony page and hear from some of our 58 “three-peat” awardees who have shared what the award means to them. If you missed out on qualifying for the award this year, applications for the 2021 HIRE Vets Medallion Award open on Jan.

30, 2021. We would love to provide you with resources to help build your veterans employment program..

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