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J Neurol Neurosurg Psychiatry 1989;52:1236– 1992;305:673–678 purchase levitra plus from india erectile dysfunction ed drugs. Neuropathological and biochemical studies of six pa- Psychiatry 1993;162:385–392 cheap levitra plus generic zopiclone impotence. The Lewy body variant pathological findings in Lewy body dementias. Psychiatric features in diffuse ical aspects of differential diagnosis. Neurobiol Aging 1998; Lewy body disease: findings in 28 pathologically diagnosed 19:S4. J Neurol Neurosurg Psychiatry 1996;60:531– 1999;96:13450–13455. Acta Neuropathol 1996;91: Int J Geriatr Psychiatry 2000;15:267–273. Neu- (A beta) deposition in dementia with Lewy bodies: predomi- rology 1998;51:351–357. Simple standardised neuro- amyloid subtypes 40 and 42 differentiates dementia with Lewy psychological assessments aid in the differential diagnosis of bodies from Alzheimer disease. Lewy body type and Alzheimer type are biochemically distinct 35. REM sleep behavior in terms of paired helical filaments and hyperphosphorylated disorder and degenerative dementia: an association likely reflect- tau protein. Prevalence of par- disease is usually the Lewy body variant, and vice versa. J Neuro- kinsonian signs and associated mortality in a community popu- pathol Exp Neurol 1993;52:648–654. A clinically and neuropathologically distinct form Ageing 1999;28:401–409. Comparison of extrapyrami- robiol Aging 1997;18:S1–S2. J Neurol Neurosurg Psychiatry 1989; Lewy bodies: reliability and validity of clinical and pathologic 52:709–717. A detailed phenomeno- and sporadic and familial dementia with Lewy bodies. Neuro- logical comparison of complex visual hallucinations in dementia report 1998;9:3925–3927. Report of the second demen- Ann Neurol 1995;37:110–112. Clin Neuropharmacol 1994;17: tion of diagnostic criteria for dementia with Lewy bodies. Apolipoprotein E epsilon4 disorder and dementia: cognitive differences when compared is associated with neuronal loss in the substantia nigra in Alzhei- with AD. The apolipo- tivities in Lewy body dementia: relation to hallucinosis and protein E epsilon 4 allele increases the risk of drug-induced extrapyramidal features. The CCTTT polymorphism in Neural Transm 1999;106:525–535. Failure to find an associa- muscarinic receptors in dementia of Alzheimer, Parkinson and tion between an intronic polymorphism in the presenilin 1 gene Lewy body types. J Neurol Neurosurg Psychiatry alpha-1 anti-chymotrypsin polymorphism genotyping in Alz- 1999;67:209–213. Butyrylcholinesterase otoxin and nicotine binding in the thalamus. J Neurochem 1999; K: an association with dementia with Lewy bodies. Correlation neuropathology, cholinergic dysfunction and synapse density. What is the neuropathological Neurobiol Aging 1998;19:S207. Striatal dopami- 'prefrontal' and 'limbic' functions. Delayed emergence nergic activities in dementia with Lewy bodies in relation to of a parkinsonian disorder in 38% of 29 older men initially 1314 Neuropsychopharmacology: The Fifth Generation of Progress diagnosed with idiopathic rapid eye movement sleep behavior of the Alzheimer-type and diffuse Lewy body disease. Psychol Med 1999;29: dopaminergic degeneration in dementia with Lewy bodies. Dementia with Lewy atrophy on MRI in dementia with Lewy bodies. Neurology 1999; bodies: a study of post-synaptic dopaminergic receptors with 52:1153–1158. MR-based hippo- of dementia with Lewy bodies: a case series of nine patients. Neuroleptic sensitivity from normal ageing, depression, vascular dementia and other to clozapine in dementia with Lewy bodies. Diagnostico clinico with Lewy bodies: a clinical study. Int J Geriatr Psychiatry 1999; de la demencia asociada a cuerpos de Lewy corticales. Medial temporal type—a review of clinical and pathological features: implica- and whole-brain atrophy in dementia with Lewy bodies: a volu- tions for treatment. Lancet 1996; plications for neurodegenerative disorders. J merous and widespread alpha-synuclein-negative Lewy bodies Neurol Neurosurg Psychiatry 1992;55:1182–1187. Validity of current clinical different types of dementia. Sensitivity and specificity 123I-beta-CIT single-photon emission tomography in dementia of three clinical criteria for dementia with Lewy bodies in an Chapter 91: Dementia with Lewy Bodies 1315 autopsy-verified sample. Int J Geriatr Psychiatry 1999;14: prospective neuropathological validation study. Neurotransmitter systems in diagnostic criteria for the diagnosis of neurodegenerative de- dementia. Validity of clinical pathological and conceptual issues. Eur Arch Psychiatry Clin criteria for the diagnosis of dementia with Lewy bodies. Predictive accuracy A distinct non-Alzheimer dementia syndrome?

No abnormalities have been detected which can be attributed to ECT trusted levitra plus 400 mg guaranteed erectile dysfunction treatment. Memory and ECT Loss of memory strikes at the sense of autonomy and is fundamentally threatening to the individual purchase levitra plus 400 mg line does erectile dysfunction cause low libido. Two recent developments have reduced the memory disturbance associated with ECT. First, the introduction of stimulation by brief (1 ms) square waves. Early ECT devices delivered sine waves, which have limited stimulation potential relative to the amount of energy they deliver, and the unnecessary energy greatly disturbed memory. Second, was the introduction of unilateral ECT, which is not usually associated with the subjective experience of memory difficulties (Squire and Slater, 1983). Major depression per se, perhaps through distractibility and perhaps through the slowing of thought processes, has a detrimental effect on memory. Also, many antidepressants (the alternative treatment) may also have a mild, temporary, detrimental effect on memory. Thus people who suffer an episode of major depression may have a poor memory for this period of their lives whether they had ECT or not. Using sophisticated neuropsychological testing methods, disturbance of memory can sometimes be demonstrated following ECT (Schulze-Rauchenbach et al, 2005). Memory difficulty is the most commonly claimed side effect of ECT. Frequently, no objective evidence can be demonstrated. However, as Vamos (2008) points out, despite the low correlation, both perspectives must be taken into consideration. The following summarize our present knowledge regarding ECT and memory: • Memory difficulties may follow ECT, and while these usually subside within a few weeks, evidence indicates that some individual have long term difficulties. This may be extended by the introduction of ultra-brief pulses. Case history, 1 Harold Watts was an accountant of 44 years of age, he was married to Ellen and the father of Josephine aged 21, who had recently married, and Paula aged 19, who had recently left home to live in a de facto relationship. Harold was brought to hospital by ambulance, accompanied by police, Ellen and a next-door neighbour. Ellen had gone to investigate two loud noises in the garage. She had found Harold on the floor next to an overturned chair, apparently dead. She rushed to her friends next door and they ran back with her. By this time Harold was beginning to move and groan on the floor. There was a belt tied to a rafter with the buckle end hanging down. The first noise Ellen heard may have been the jerking of the rafter or the chair falling over, and the second, some moments later, may have been when the buckle broke and Harold landed on the floor. The ambulance officers noted thick purple marks around his neck and that the whites of his eyes were pinkish. The police were shown the hanging belt and Harold was taken to hospital. Harold was orientated in time, place and person and an X-ray of his neck revealed no bony abnormality. He could move all limbs and did not appear to have sustained any permanent physical damage. He cried and said he was just missing “the girls” since they both left home about the same time. Ellen, a neighbour, a hospital doctor and an ambulance officer were discussing the situation in the corridor. Ellen was saying she would take Harold home and perhaps they should take a holiday together, when a nurse passing his cubicle noticed Harold was attempting to strangle himself with the leads of a cardiac monitor. They rushed back, removed the leads and called a psychiatrist. Harold had been drinking excessively over the last month. He denied feeling depressed, but had been moved to tears when watching sentimental television programs. He had been preoccupied with thoughts of his dead parents and dead brother. He had found himself thinking about cemeteries and his own funeral. He then started to experience strong urges to kill himself. He could not explain these urges, nor could he guarantee he would not act on them. Harold was transferred to a psychiatric ward for observation, with a probable diagnosis of major depressive disorder. There was some uncertainty as he denied feeling depressed. However, depressed mood is not always a prominent complaint in major depression, in which case the term “masked depression” may be applied. Supporting the diagnosis of depression was the history of preoccupation with death and sad events, and self-destructive urges. Within and hour of admission to the psychiatric ward Harold again performed self- destructive behaviour. He asked to go to the toilet and was allowed access to a specially designed facility which contained no cloth towels and no suspension points from which one could hang, and no sharp edges with which cutting could be performed. Soon after he had been left alone a heavy thud was heard. Harold was found on the floor outside the toilet cubicle in a pool of blood and with a large laceration on the top of his head. He had climbed up and stood on the wall of the toilet cubicle and divided down head first onto the floor. This was a resourceful and determined attempt and left no doubt that Harold was a danger to himself. He revealed that he had been feeling guilt as if he was responsible for events which he heard about on the news, even events on the other side of the world. He had not admitted this when brought into hospital because he felt ashamed.

The south-east region (including Rio de Janeiro and Sao Paulo) carried out 40% of all projects and received 60% of funds order levitra plus american express erectile dysfunction medication list. The research has helped to improve treatments order levitra plus online now erectile dysfunction meds, prevention and diagnoses, to develop new products and services, and to strengthen the patient-oriented health-care system (44). AIDS, acquired immunodefciency syndrome; HIV, human immunodefciency virus; MDGs, Millennium Development Goals. The role of health ministries in developing research capacity: the examples of Guinea Bissau and Paraguay The Guinea Bissau health research system has evolved under the strong influence of international donors and technical partners who have provided funds and scientific expertise (51). Research has been carried out chiefly by the Bandim Health Project, the National Laboratory for Public Health, the Department of Epidemiology and the Instituto Nacional de Estudos e Pesquisa (INEP) which is oriented to the social sciences. Research priorities have been set largely by expatriate researchers and have focused on understanding and reducing child mortality. Recognizing the need to set national research priorities, align funding, build local research capacity and link research to decision-making, the Ministry of Health established the National Institute of Public Health (INASA) in 2010. External technical support is led by the West African Health Organisation (WAHO), which works in partnership with the Council on Health Research for Development (COHRED) and the International Development Research Centre (IDRC). The commitment of the Ministry of Health to invest in research has been central to success. The main challenges facing Guinea Bissau are the limited number of skilled researchers and dependence on foreign assistance. Paraguay has a stronger research base than Guinea Bissau, with more staff and institutions engaged in health research. In 2007, therefore, the Ministry of Health formed a new directorate for research and in 2009 set up an inter-institutional committee to create a framework for health research. The committee included the Minister of Education and representatives of UNICEF and the Pan American Health Organization. Drawing on the experience of other countries, and especially Mexico, the commit- tee drafted a government policy on research for health and set up the first National Council of Research for Health. As part of the drive to improve health research, all research institutions in the country are under evaluation. An online database of researchers has been created, and only registered researchers are eligible for funding from the Council of Science and Technology. The database provides information about the training of researchers, their experience, and current research topics. The intention is to manage dedicated funding through a health research trust and to allocate these funds transparently on merit. As in Guinea Bissau, the support of the Minister of Health backed by the President of Paraguay has been a key factor in the development of a national health research system. Examples of eforts to build research capacity, ranging from individual to global movements Supranational health research bodies National health research systems Organizational development Institutional development National health research councils Individual training WHO / TDR US NIH Wellcome Trust TDR, Special Programme for Research and Training in Tropical Diseases; US NIH, United States National Institutes for Health. Adapted, by permission of the publisher, from Lansang & Dennis (52). Te decision to build and strengthen research any setting depends on the strategic vision for capacity, and to allocate the necessary funds, is the research and what is needed from research. Tus the Task Force on Malaria Research include a skilled and self-confdent workforce Capability Strengthening in Africa is part of the with strong leadership, adequate funding with Multilateral Initiative on Malaria, which is coor- transparent and accountable methods for allo- dinated by the Special Programme for Research cating funds, and well equipped research institu- and Training in Tropical Diseases (TDR). Views also difer on the emphasis to be placed One framework for capacity-building, on, for example, building elite institutions, cre- which has the ingredients of many others, is ating international networks, boosting transla- represented in Fig. A framework to guide capacity-building, highlighting approaches and targets, the likelihood of sustainability, and the research focus Entity targeted Approach to capacity strengthening Graduate or Learning Institutional partnerships Centres of postgraduate training by doing between countries excellence Individuala +++ + ++ + Institution +++ ++ +++ +++ Network ++ ++ +++ ++ National level + ++ ++ +++ Supranational level ++ +++ ++ Financial investmentb ++ + +++ +++ Research focus Research skills Programme, policy, systems development Likelihood of + +++ sustainabilityc a Plus (+) signs indicate the entity is targeted + sometimes, ++ often, +++ frequently. Reproduced, by permission of the publisher, from Lansang & Dennis (52). For instance, of activities mattered more during the expan- graduate and postgraduate training are more sion stage. Funding for core activities and local likely to be efective when the host institutions management were vital during the consolidation are also strong (Table 4. From the outset, any programme to Te following sections look more closely at strengthen research capacity must defne, moni- three elements of capacity that are universally tor and evaluate success – an area in which important: building the research workforce, knowledge is still sparse (52, 53, 58–60). A simple tracking fnancial fows, and developing institu- geographical mapping of research activity can be tions and networks. One evalu- Creating and retaining a ation examined which indicators of research skilled research workforce capacity were most useful in four diferent set- tings: evidence-based health care in Ghana, The world health report 2006 − working together HIV voluntary counselling and testing services for health highlighted the critical role, and the in Kenya, poverty as a determinant of access to chronic shortage, of health workers, especially TB services in Malawi, and the promotion of in low-income countries (62). Here the vital community health in the Democratic Republic contribution made by health researchers as of the Congo (6). Te most expedient indicators part of the health workforce is underscored changed as programmes matured. Geographical distribution of research capacity in Africa Research output (Number of articles per city) 31–99 100–249 250–499 500–999 >1000 R&D, research and development. Note: Mapping of top 40 African cities by research output shows hotspots and coldspots of R&D activity and highlights inequi- ties in R&D productivity across the continent. Alongside the numerous exam- courses ofered by the International Union ples of “north–south” research collaboration run against Tuberculosis and Lung Disease and a variety of training schemes for young research- Médecins Sans Frontières (MSF) Luxembourg ers – such as those ofered by TDR (www. Even where there are shortages of money int/tdr), the Training Programs in Epidemiology to do the research in Africa, there is an appe- and Public Health Interventions Network tite for career development through mentorship 104 Chapter 4 Building research systems for universal health coverage Box 4. Principles of research partnership Further details of these 11 principles can be found in Guidelines for research in partnership with developing countries prepared by the Swiss Commission for Research Partnership with Developing Countries (64). The 11 principles (with minor adaptation) are as follows: 1. Decide on research objectives together, including those who will use the results. Build mutual trust, stimulating honest and open research collaboration. Share information and develop networks for coordination. Create transparency in financial and other transactions. Monitor and evaluate collaboration, judging performance through regular internal and 1. Disseminate the results through joint publications and other means, with adequate communication to those who will finally use them. Apply the results as far as is possible, recognizing the obligation to ensure that results are used to benefit the target group. Share the benefits of research profits equitably including any profit, publications and patents. Increase research capacity at individual and institutional levels. Build on the achievements of research – especially new knowledge, sustainable development and research capacity. For instance, African research- contrast, research spending by two national ers have argued that support for research on health departments (England and Scotland) is neglected tropical diseases should not be the oriented to treatment evaluation, disease man- sole responsibility of external donors.

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