text:
Electroconvulsive therapy
Electroconvulsive therapy | |
Intervention | |
MeSH | D004565 |
OPS-301 code: | 8-630 |
MedlinePlus | 007474 |
Electroconvulsive therapy (ECT), formerly known as electroshock, is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses.[1] ECT is usually used as a last line of intervention for major depressive disorder, schizophrenia, mania and catatonia.[2] A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer depressed. It was first introduced in 1938 by Italian neuropsychiatrists Ugo Cerletti and Lucio Bini, and gained widespread popularity among psychiatrists as a form of treatment in the 1940s and 1950s.[3][4]
In western fiction, it is usually depicted as a painful procedure, but in western countries ECT is administered under anesthetic with a muscle relaxant.[5]
About 70 percent of ECT patients are women, possibly because they are at twice the risk of depression as men.[1][6][7] Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive, and successful ECT is usually followed by medication treatment. Administration is most commonly bilateral, in which the electrical current is passed across the whole brain, and which seems to have greater efficacy but greater risk of memory loss, or less commonly, unilateral, which has less efficacy but also reduced risk of memory loss.[8][9] The World Health Organization (2005) advises that it should be used only with the informed consent of the patient or their proxy, only with adequate analgesia and muscle relaxants, and never on children.[10] Psychiatrists and other mental health professionals differ on when and if ECT should be used as a first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.[11] ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.[12]
Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT. In the United Kingdom and Ireland, drug therapy usually is continued during ECT.[2]
As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal.[1] Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol).[13][14] Ladislas Meduna is thought to be the father of convulsive therapy.[15] In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide.[14] Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1937, experimented for the first time on a person. It was known early on that inducing convulsions aided in helping those with severe schizophrenia. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state.[16] Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients they found that after 10-20 treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it.[16] ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient.[17] Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread.
In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted.[18] In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.[18]
The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media."[19] The New York Times described the public's negative perception of ECT as being caused mainly by one movie. "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".[20]
In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices.[21] The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT.[22] Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression".[19] In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.[23]
Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, The American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.
Mechanism of action[edit]
Despite decades of research, the exact mechanism of action of ECT remains elusive. Ladislas J. Meduna believed that chemically induced seizures, brought on by drugs, could change the chemical makeup of the brain of a patient with schizophrenia. Modern electroconvulsive therapy operates under a similar hypothesis, though in modern practice a therapeutic clonic seizure is induced by electrical current via electrodes placed on an anesthetized, unconscious patient. It is known that the central nervous system is regulated by small electrical current; disrupting or "restarting" that current by induced seizure (colloquially, "jumpstarting the brain"), has shown positive effects in patients with severe depression or schizophrenia.[15]
Peter Breggin, an outspoken and controversial critic of evidence-based psychiatry, claims that ECT induces "a closed-head injury caused by an overwhelming current of electricity sufficient to cause a grand mal seizure" and that the improvements in mood seen in patients receiving ECT are resultant from brain damage.[24] Such claims are rejected as wholly unsubstantiated by the consensus of the scientific and medical community.[25][26][27]
There is a vast body of literature on the effects of ECT in animals; however, though human and animal brains are very similar, animal models of depression are widely acknowledged to parallel only limited aspects of depressive illness, a uniquely human disease. Some suggest pruning of normally dense synaptic connections in the hippocampus, a richly connected area deep in the temporal lobe vital in controlling both mood and memory, seen in animal studies may play a role in its effectiveness.[28]
Selection of patients for ECT[edit]
Experts disagree on whether ECT is an appropriate first-line treatment or if it should be reserved for patients who have not responded to other interventions such as medication and psychotherapy.[11]
The American Psychiatric Association 2001 guidelines give the primary indications for ECT among patients with depression as a lack of response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference and capacity to consent, and a weighing of the risks and benefits.[29]
Some guidelines[which?] recommend cognitive behavioral therapy or other psychotherapy before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants at adequate doses for an adequate duration and with good compliance. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.
The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions where there is a clear consensus favoring early ECT. The UK's National Institute for Health and Clinical Excellence 2003 (NICE) guidelines recommended ECT for patients with severe depression, catatonia, or prolonged or severe mania. It did not recommend the use of ECT as a maintenance therapy in depressive illness as "the long-term benefits and risks ... had not been clearly established"[25]:5–6 and those recommendations were unchanged in the 2010 update.[30]:526 The 2001 APA guidelines support the use of ECT for relapse prevention.
The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia, but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for schizophrenia, and this has been supported by meta-analytic evidence showing no or little benefit versus placebo, or in combination with antipsychotic drugs, including Clozapine.[31]
The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.
ECT has been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations and hydrocephalus.[32]
Non-clinical patient characteristics[edit]
About 70 percent of ECT patients are women.[1] This may be due to the fact that women are more likely to be diagnosed with depression.[1][6] Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.[6][33]
Degree of effectiveness and risks[edit]
Scientific papers and articles reviewing studies of ECT effectiveness have reached conflicting conclusions.
A meta-analysis done on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Findings showed that although patients with unipolar depression and bipolar depression responded very differently to other medical treatments both groups responded equally as well to ECT. Overall remission rate for patients with unipolar depression was 51.5% and 50.9% in those with bipolar depression. The severity of each patient's depression was assessed at the same baseline in each group.[34]
In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.[35]
In 2006, a research article by Dr. Colin A. Ross found that no studies had ever shown that ECT was more effective than a placebo (sham ECT) treatment as of 1 month posttreatment.[36]
In 2008, a meta-analytic review paper found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs."[37]
In 2010, a paper by Dr. John Reed and Dr. Richard Bentall found that ECT was only minimally more effective than a placebo during the treatment period, and that there was no difference in effect after the treatment period. In light of this finding, and the risk of side-effects, the authors concluded that the use of ECT "cannot be scientifically justified".[9]
A 2011 paper in the Journal of Psychiatric Nurses Association reported that ECT was effective.[38]
Surveys of public opinion, the testimony of former patients, legal restrictions on its use and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial.[39][40][41][42][43][44] This is reflected in the recent vote by the United States Food and Drug Administration's (FDA's) Neurological Devices Advisory Panel to recommend that FDA maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time.[45][46][47] In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.[48]
Duration of effect[edit]
ECT on its own does not usually have a sustained benefit. Half of those who remit then relapse within six months. This is similar to the rate of relapse after discontinuing antidepressant medication, and it has been suggested that it is due to the severity and chronicity of pre-existing illness for which ECT is generally used.[49] The relapse rate in the first six months is reduced by the use of psychiatric medications or further ECT, but remains high.[50][51]
Probability of remission[edit]
The 1999 U.S. Surgeon General's Report on Mental Health summarized psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical experience and published studies had determined ECT to be effective (with an average 60 to 70 percent remission rate) in the treatment of severe depression, some acute psychotic states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals.[52]
A 2004 large multicentre clinical follow-up study of ECT patients in New York — describing itself as the first systematic documentation of the effectiveness of ECT in community practice in the 65 years of its use — found remission rates of only 30 to 47 percent, with 64 percent of those relapsing within six months.[53] However, when patients with co-morbid personality disorders or who were suffering from schizoaffective disorder were removed from the analysis, the remission rates climbed to 60-70%.[53]
Related experimental therapeutics[edit]
Recent research has investigated whether implantable devices such as those used in DBS (deep brain stimulation) could result in clinical improvements for patients with treatment-resistant depression. However, in North America, DBS has not been authorized as an approved, effective therapy for treatment-resistant depression.
Adverse effects[edit]
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the U.S. Surgeon General's report says that there are "no absolute health contraindications" to its use.[52]:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after a few hours. It can be tolerated by pregnant women who are not suffering major complications. It can be used with diabetic or obese patients, and with caution in those whose cancers are in remission or under control. It can be used in some immunocompromised patients. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well controlled.[54][55] Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. ECT, especially if combined with deep sleep therapy, may lead to brain damage if administered in such a way as to lead to hypoxia or anoxia in the patient.[56][57][58] The death rate due to ECT is around 4 per 100,000 procedures.[59] There is evidence and rationale to support giving low doses of benzodiazepines or else low doses of general anesthetics which induce sedation but not anesthesia to patients to reduce adverse effects of ECT.[60]
Effects on memory[edit]
It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.[61] The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment).[62] Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses as opposed to a steady flow seemed to incur less memory loss. The vast majority of modern treatment uses brief pulse currents.[62]
Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being memories in the weeks and months prior to the treatment.[63][64] Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT.[1][62] One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes.[65] In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.[61]
Controversy over long-term effects on general cognition[edit]
A number of reviews of the literature and other articles continue to characterize ECT as safe and effective.[66][67][68][69][70][71][72][73] For example, in June 2009, Portuguese researchers published a review on the safety and efficacy of ECT in an article entitled, Electroconvulsive Therapy: Myths and Evidences.[66] In their review, the researchers conclude that ECT is an "efficient, safe and even life saving treatment for several psychiatric disorders." In 2008, Yale researchers published a review on the safety and efficacy of ECT in elderly patients.[73] According to the authors, "ECT is well established as a safe and effective treatment for several psychiatric disorders." And in a June 2009 article published in the Journal of ECT, Iranian researchers observe that, "Despite the wide consensus over the safety and efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and unfavorable attitudes of patients and families."[72]
Effects on brain structure[edit]
Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations — including the American Psychiatric Association — have concluded that there is no evidence that ECT causes structural brain damage.[25][26][27] A 1999 report by the U.S. Surgeon General states, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals".[74]
Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT, stated in a 2007 interview[75] that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites a study[76] purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Dr. Kellner stated "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."
Effects in pregnancy[edit]
If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments.[77][dead link][78][79] Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended.[77] Much of the medical literature in this area is composed of case studies of single or twin pregnancies, and although some have reported serious complications,[80][81] the majority have found ECT to be safe.[82]
ECT is selected as a therapy as described above, and normally requires the informed consent of the patient.[1]:1880
Whether psychiatric medications are terminated prior to treatment or maintained, varies.[1]:1885[83] However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase seizure thresholds, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.[1]:1879:1875
The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.[1]:1881
In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective if the dose administered is close to the seizure threshold.[1]:1881 In the USA most patients receive bilateral ECT.[84] In the UK almost all patients receive bilateral ECT.[8][85]
The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.[1]:1881 Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains.[86] Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex.[84] Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.
Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental,[1] a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation. The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.[1]:1882
ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.[1]:1882–1883
ECT devices[edit]
Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT.[1] A small minority of psychiatrists in the USA still use sine-wave stimuli.[84] Sine-wave is no longer used in the UK or Ireland.[85] Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds.[86] In the USA, ECT devices are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta.
In the UK, the market for ECT devices was long monopolized by Ectron Ltd, although in recent years some hospitals have started using American devices. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a colleague from the Three Counties Asylum, Bedfordshire, invented the Page–Russell technique of intensive ECT.
Regulatory status in the US[edit]
In the United States, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration; when the law came into effect the FDA was obligated to retrospectively review already-existing devices and classify them, and determine whether clinical trials were needed to prove efficacy and safety. While the FDA has classified the devices used to administer ECT as Class III medical devices, as of 2011 the FDA had not yet determined whether the devices should be withdrawn from the market until clinical trials prove their safety and efficacy.[45][46][47]:5The FDA considers ECT machinery to be experimental devices, experimental since 1930.[87]
Variations in international practice[edit]
There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists.[1] International practice varies considerably from widespread use of the therapy in many western countries to a small minority of countries that do not use ECT at all, such as Slovenia.[88] Guidelines on the use of ECT are stringent in the USA and the UK. Modern standards are not always followed throughout the world and not all countries that use ECT have written technical standards. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified ECT. In a minority of countries such as Japan,[89] India,[90] and Nigeria,[91] ECT may be used without anesthesia. WHO has called for a worldwide ban on unmodified ECT and the topic is currently being debated in countries like India. The practice has been recently abolished in Turkey's largest psychiatric hospital.[92] A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthesiologists available to administer the procedure.[93] A small minority of countries never seek consent before administering ECT. This significantly uneven application of ECT around the world continues to make ECT a controversial procedure.
Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who swear by it, and some patients and families of patients who say that their lives have been ruined by it. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".[94]
United States[edit]
ECT became popular in the United States in the 1940s. At this time psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. The practices of ECT and lobotomies became popular because they held some promise of addressing the overpopulation problem. Whereas lobotomies would reduce a patient to a more manageable submissive state ECT helped to improve mood in those with severe depression. In the United States, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas.[95] Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information.[96] In 13 of the 50 states, the practice of ECT is regulated by law.[97] One state which does report such data is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually.[6] Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen).[98] ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics.[1] In the United States, ECT is usually given three times a week; in the UK, it is usually given twice a week.[1] Occasionally it is given on a daily basis.[1] A course usually consists of 6–12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals.[1] A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic.[1] Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option: no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.[99]
United Kingdom[edit]
In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then[100] to about 12,000 per annum in 2002.[101] It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent.[101] In 2003, the National Institute for Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".[102]
The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal[103] but the Royal College of Psychiatrists launched an unsuccessful appeal.[104] The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure.[105] A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.[106]
The Union Health Ministry of India has decided in the Mental Health Care Bill of 2010 that they will no longer use unmodified (no anesthesia) ECT. The Health Ministry recommended a ban on the whole procedure.[107]
Legal status[edit]
Informed consent[edit]
The World Health Organization (2005) advises that ECT should be used only with the informed consent of the patient (or their guardian if their incapacity to consent has been established).[10]
In the US, this doctrine places a legal obligation on a doctor to make a patient aware of: the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that consent may be revoked and treatment discontinued at anytime during a course of ECT.[52] The Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT.[52] The report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.
To demonstrate what he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form[108] using the consent form developed and enacted by the Texas Legislature[109] as a model.
According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. The use of ECT is believed to be a potentially life-saving treatment.[74]
In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.[110]
In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects.[111] One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects[112] and another survey found that about fifty percent of psychiatrists and nurses agreed with them.[113]
A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT.[112] The study found that, "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:
"Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales."[112]
Involuntary ECT[edit]
Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed. Involuntary electroshock contravenes the principle of autonomy in medical ethics. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to consent to, or to refuse a medical treatment, such as ECT. Persons considered not to be of sound mind are in many jurisdictions considered incapable of giving true consent. In such a case, the patient's "assent" may be sought; opinions are divided as to whether this should be routinely done, or whether a patient who is not competent to consent to therapy should retain the right to refuse it.
Citizens in western societies often undergo emergency medical procedures when they have lost the capacity to consent (such as neurosurgery after head injury). Under these circumstances, the principles of beneficence and non-maleficence must be adhered to.
United States[edit]
In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. Patients may be represented by legal counsel at the hearing. According to the Surgeon General's Report on Mental Health, "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia."[52] However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective.
United Kingdom[edit]
Until 2009 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2009, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act.[114] In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent).[115] However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization.[116] About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act.[117] Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy.[118] In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.[119]
Patient experience[edit]
NICE ECT guidelines report that some individuals consider ECT to have been a beneficial and lifesaving treatment, while others reported feelings of terror, shame and distress, and found it positively harmful and an abusive invasion of personal autonomy, especially when administered without their consent.[120]
Historical accounts[edit]
Ernest Hemingway, American author, committed suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient...."[121]
In a poem, The Hanging Man, by Sylvia Plath ECT is described:
By the roots of my hair some god got hold of me.
I sizzled in his blue volts like a desert prophet.
The nights snapped out of sight like a lizard's eyelid:
A world of bald white days in a shadeless socket.
A vulturous boredom pinned me in this tree.
If he were I, he would do what I did.
Public perception and mass media[edit]
A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.[44]
Fictional examples[edit]
Electroconvulsive therapy has been depicted in fiction and works based on true experiences. These include A Clockwork Orange, Requiem for a Dream, A Beautiful Mind and One Flew Over The Cuckoo's Nest.
See also[edit]
- ^ a b c d e f g h i j k l m n o p q r s t u v Rudorfer, MV, Henry, ME, Sackeim, HA (2003). "Electroconvulsive therapy". In A Tasman, J Kay, JA Lieberman (eds) Psychiatry, Second Edition. Chichester: John Wiley & Sons Ltd, 1865–1901.
- ^ a b Scott AIF (ed) et al. (2005). "The ECT Handbook Second Edition: The Third Report of the Royal College of Psychiatrists' Special Committee on ECT" (PDF). Royal College of Psychiatrists. Retrieved 2008-07-26.[dead link]
- ^ Shorter, Eward (2007). A History of Electroconvulsive Treatment in Mental Illness. New Brunswick, NJ: Rutgers University Press. pp. 46–47. ISBN 978-0-8135-4169-3.
- ^ Psychology Frontiers and Applications – Second Canadian Edition (Passer, Smith, Atkinson, Mitchell, Muir)
- ^ http://psychcentral.com/lib/5-outdated-beliefs-about-ect/00011255
- ^ a b c d Reid WH, Keller S, Leatherman M, Mason M (January 1998). "ECT in Texas: 19 months of mandatory reporting". J Clin Psychiatry 59 (1): 8–13. doi:10.4088/JCP.v59n0103. PMID 9491059.
- ^ http://umm.edu/health/medical/reports/articles/depression
- ^ a b Dr.Barnes, Richard. "Information on ECT". Royal College of Psychiatrists' Special Committee on ECT and related treatment. Retrieved 3 November 2013.
- ^ a b Read, J; Bentall, R (2010 Oct-Dec). "The effectiveness of electroconvulsive therapy: a literature review.". Epidemiologia e psichiatria sociale 19 (4): 333–47. doi:10.1017/S1121189X00000671. PMID 21322506.
- ^ a b World Health Organisation (2005). WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva, 64.
- ^ a b American Psychiatric Association, Committee on Electroconvulsive Therapy, Richard D. Weiner (chairperson) et al. (2001). The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (2nd ed.). Washington, DC: American Psychiatric Publishing. ISBN 978-0-89042-206-9.
- ^ http://ps.psychiatryonline.org/article.aspx?articleID=77626
- ^ Berrios, G E (1997). "The scientific origins of electroconvulsive therapy". History of Psychiatry 8 (29 pt 1): 105–119. doi:10.1177/0957154X9700802908. PMID 11619203.
- ^ a b Fink, M (1984). "The origins of convulsive therapy". American Journal of Psychiatry 141 (9): 1034–41. PMID 6147103.
- ^ a b Bolwig, T. (2011). "How does electroconvulsive therapy work? Theories on its mechanism". The Canadian Journal of Psychiatry 51 (1): 13–18. PMID 21324238.
- ^ a b Sabbatini, R. "The history of shock therapy in psychiatry". Retrieved 2013-04-24.
- ^ Cerletti, U (1956). "Electroshock therapy". In AM Sackler et al. (eds) The Great Physiodynamic Therapies in Psychiatry: an historical appraisal. New York: Hoeber-Harper, 91–120.
- ^ a b Kiloh, LG, Smith, JS, Johnson, GF (1988). Physical Treatments in Psychiatry. Melbourne: Blackwell Scientific Publications, 190–208. ISBN 0-86793-112-4
- ^ a b Goode, Erica (1999-10-06). "Federal Report Praising Electroshock Stirs Uproar". New York Times. Retrieved 2008-01-01.
- ^ Goleman, Daniel (1990-08-02). "The Quiet Comeback of Electroshock Therapy". The New York Times. p. B5. Retrieved 2008-01-01.
- ^ Leiknes KA, et al (2012) Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav. 2(3):283-344
- ^ See Friedberg, J (1977). "Shock treatment, brain damage, and memory loss: a neurological perspective". American Journal of Psychiatry 134:1010–1014; and Breggin, PR (1979) Electroshock: its brain-disabling effects. New York: Springer
- ^ Blaine, JD; Clark, SM (1986). "Report of the NIMH–NIH consensus development conference on Electroconvulsive therapy". Psychopharmacology Bulletin 22 (2): 445–452.
- ^ Dr. Peter Breggin for Huffington Post. February 9, 2008. Brain-Disabling Treatments in Psychiatry: Drugs, Electroshock and the Psychopharmaceutical Complex
- ^ a b c "Guidance on the use of electroconvulsive therapy" (PDF). National Institute for Clinical Excellence. April 2003. Retrieved 2008-07-26.
- ^ a b Department of Health (September 2009). Electroconvulsive therapy - About your rights. Melbourne, Victoria: Mental Health and Drugs Division, Victorian Government, Department of Health. 090806.
- ^ a b American Psychiatric Association. "Electroconvulsive Therapy (ECT)". Retrieved 2007-12-29.[dead link]
- ^ Krishnan et al. (October 2008). "The molecular neurobiology of depression". Nature 455 (1): 894–902. Bibcode:2008Natur.455..894K. doi:10.1038/nature07455. PMC 2721780. PMID 18923511.
- ^ Lisanby, S.H. (2007) Electroconvulsive Therapy for Depression Volume 357, No. 19, pp. 1939–1945
- ^ "Depression in adults (update)" (PDF). National Institute for Clinical Excellence. 2010. p. 526. Retrieved 2010-05-24.
- ^ Tharyan, P. Adams, C.E. (2005). "Electroconvulsive therapy for schizophrenia". In Tharyan, Prathap. The Cochrane Database of Systematic Reviews (2): CD000076. doi:10.1002/14651858.CD000076.pub2. PMID 15846598.
- ^ Murray ED, Buttner N, Price BH (2012). "Depression and Psychosis in Neurological Practice". In Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Bradley's Neurology in Clinical Practice: Expert Consult - Online and Print, 6e (Bradley, Neurology in Clinical Practice e-dition 2v Set) 1 (6th ed.). Philadelphia, PA: Elsevier/Saunders. pp. 114–115. ISBN 1-4377-0434-4.
- ^ Euba R, Saiz A (2006). "A comparison of the ethnic distribution in the depressed inpatient population and in the electroconvulsive therapy clinic". J ECT 22 (4): 235–6. doi:10.1097/01.yct.0000235928.39279.52. PMID 17143151.
- ^ Dierckx, B.; Heijnen, WT; Van Den Broek, WW; Birkenhäger, TK (2012). "Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: A meta-analysis". Bipolar Disorders 12 (2): 146–150. doi:10.1111/j.1399-5618.2012.00997.x. PMID 22420590.
- ^ UK ECT Review Group (2003). "Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis". The Lancet 361 (9360): 799–808. doi:10.1016/S0140-6736(03)12705-5. PMID 12642045.
- ^ Ross CA (2006). "The sham ECT literature: implications for consent to ECT". Ethical Human Psychiatry and Psychology 8 (1): 17–28. doi:10.1891/ehpp.8.1.17. PMID 16856307.
- ^ Daniel Pagnin, M.D., M.Sc.; Valéria de Queiroz, M.D., M.Sc.; Stefano Pini, M.D.; Giovanni Battista Cassano, M.D. "Efficacy of ECT in Depression: A Meta-Analytic Review". Focus.
- ^ http://jap.sagepub.com/content/17/3/217.short
- ^ Philpot, M; Treloar, A; Gormley, N; Gustafson, L (2002). "Barriers to the use of electroconvulsive therapy in the elderly: a European survey". European Psychiatry 17 (1): 41–45. doi:10.1016/S0924-9338(02)00620-X. PMID 11918992.
- ^ Whitaker, Robert (2010). Mad in America : bad science, bad medicine, and the enduring mistreatment of the mentally ill (Rev. pbk. ed.). New York, NY: Basic Books. pp. 102–106. ISBN 978-0-465-02014-0.
- ^ Golenkov, A.; Ungvari, G. S., Gazdag, G. (21 February 2011). "Public attitudes towards electroconvulsive therapy in the Chuvash Republic". International Journal of Social Psychiatry 58 (3): 289–94. doi:10.1177/0020764010394282. PMID 21339235.
- ^ Committee on Mental Health (March 2002). "Report on Electroconvulsive Therapy". New York State Assembly. Retrieved 8 March 2011.
- ^ Melding, P (2006-07-07). "Electroconvulsive therapy in New Zealand: terrifying or electrifying?". The New Zealand medical journal 119 (1237): U2051. PMID 16862197.
- ^ a b Teh, S.P.C.; Helmes, E.; Drake, D. (2007). "A Western Australian Survey On Public Attitudes Toward and Knowledge of Electroconvulsive Therapy". International Journal of Social Psychiatry 53 (3): 247–271. doi:10.1177/0020764006074522.
- ^ a b Kellner, Charles H. (2012-07-05). "The FDA Advisory Panel on the Reclassification of ECT Devices: Unjustified Ambivalence". Psychiatric Times. UBM Medica. Archived from the original on 2012-10-25. Retrieved 2012-10-25.
- ^ a b Duff Wilson for the New York Times. January 28, 2011 F.D.A. Panel Is Split on Electroshock Risks
- ^ a b "FDA Executive Summary Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT)". United States Food and Drug Administration. Archived from the original on 2012-10-25. Retrieved 2012-10-25.
- ^ Mechcatie, Elizabeth. "FDA Regulation of ECT Devices in Transition". Clinical Psychiatry News. Retrieved 8 March 2011.
- ^ Sackeim HA, Haskett RF, Mulsant BH, Thase ME, Mann JJ, Pettinati HM, Greenberg RM, Crowe RR, Cooper TB, Prudic J.(2001) Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001 Mar 14; 285(10):1299–307.
- ^ Tew Jr, JD, Mulsant, BH, Haskett, RF, Joan, P, Begley, AE, Sackeim, HA (2007). "Relapse during continuation pharmacotherapy after acute response to ECT: a comparison of usual care versus protocolized treatment". Annals of Clinical Psychiatry 19 (1): 1–4. doi:10.1080/10401230601163360. PMID 17453654.
- ^ Kellner, CH, Knapp, RG, Petrides, G, Rummans, TA, Husain, MM, Rasmussen, K, Mueller, M, Bernstein, HJ, O'Connor, K, Smith, G, Biggs, M, Bailine, SH, Malur, C, Yim, E, McClintock, S, Sampson, S, Fink, M (December 2006). "Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE)". Archives of General Psychiatry 63 (12): 1337–44. doi:10.1001/archpsyc.63.12.1337. PMC 3708140. PMID 17146008.
- ^ a b c d e Surgeon General (1999). Mental Health: A Report of the Surgeon General, chapter 4.
- ^ a b Prudic J, Olfson M, Marcus SC, Fuller RB, Sackeim HA (2004). "Effectiveness of electroconvulsive therapy in community settings". Biol. Psychiatry 55 (3): 301–12. doi:10.1016/j.biopsych.2003.09.015. PMID 14744473.
- ^ "Electroshock". DepNet. Retrieved 2009-03-18.
- ^ "Electroconvulsive therapy – Electroshock (ECT)". DoctorsLounge. Retrieved 2009-03-19.
- ^ O'Neill, J; Haupt, Robert (2 August 1988). "The last victim of the 'beautiful hospital'". Sydney Morning Herald.
- ^ E. Wilson 2003 Psychiatric abuse at Chelmsford Private Hospital, New South Wales, 1960-1980s. In C. Coleborne and D. MacKinnon Madness in Australia: histories, heritage and the asylum. Queensland: 121-34
- ^ Susan Jane Tweedale v. Dr. John Tennant Herron & Ors., [1997] NSWSC 168 AustLII (Supreme Court of New South Wales 10 December 1996).
- ^ Gelder, M., Mayou, R., Geddes, J. (2006) Psychiatry. 3rd edition. Oxford: Oxford University Press
- ^ Gallegos J, Vaidya P, D'Agati D et al. (June 2012). "Decreasing adverse outcomes of unmodified electroconvulsive therapy: suggestions and possibilities". J ECT 28 (2): 77–81. doi:10.1097/YCT.0b013e3182359314. PMID 22531198.
- ^ a b Lisanby SH, Maddox JH, Prudic J, Devanand DP, Sackeim HA (June 2000). "The effects of electroconvulsive therapy on memory of autobiographical and public events". Arch. Gen. Psychiatry 57 (6): 581–90. doi:10.1001/archpsyc.57.6.581. PMID 10839336.
- ^ a b c Benbow, SM (2004) "Adverse effects of ECT". In AIF Scott (ed.) The ECT Handbook, second edition. London: The Royal College of Psychiatrists, pp. 170–174.
- ^ Squire LR, Slater PC, Miller PL (January 1981). "Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up". Arch. Gen. Psychiatry 38 (1): 89–95. doi:10.1001/archpsyc.1981.01780260091010. PMID 7458573.
- ^ Squire LR, Slater PC (January 1983). "Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study". Br J Psychiatry 142: 1–8. doi:10.1192/bjp.142.1.1. PMID 6831121.
- ^ Rose, D; Fleischmann, P; Wykes, T; Leese, M; Bindman, J (2003). "Patients' perspectives on electroconvulsive therapy: systematic review". British Medical Journal 326 (7403): 1363–1365. doi:10.1136/bmj.326.7403.1363. PMC 162130. PMID 12816822.
- ^ a b Coentre R et al. (May–June 2009). "Electroconvulsive therapy: myths and evidences". Acta Medica Portuguesa 22 (3): 275–80. PMID 19686628.[dead link]
- ^ Zyss T et al. (Nov–Dec 2008). "Shock therapy in psychiatry--historical feature". Psychiatrica Polska 42 (6): 797–818. PMID 19441660.
- ^ Faedda GL et al. (March 2009). "The origins of electroconvulsive therapy: Prof. Bini's first report on ECT". Journal of affective disorders. Epub Ahead of Print (1–3): 12–5. doi:10.1016/j.jad.2009.01.023. PMID 19268370.
- ^ van Herck E et al. (2009). "Electroconvulsive therapy for patients with intracranial aneurysms: a case study and literature review". Dutch Journal of Psychiatry 51 (1): 43–51.
- ^ Cristancho MA et al. (Dec 2008). "Uncommon but serious complications associated with electroconvulsive therapy: recognition and management for the clinician". Current psychiatry reports 10 (6): 474–80. doi:10.1007/s11920-008-0076-4. PMID 18980730.
- ^ Busnello JV et al. (Dec 2008). "Peripheral nucleotide hydrolysis in rats submitted to a model of electroconvulsive therapy". Prog Neuropsychopharmacol Biol Psychiatry. 32 (8): 1829–33. doi:10.1016/j.pnpbp.2008.08.007. PMID 18775464.
- ^ a b Malekian A et al. (Jun 2009). "Knowledge of attitude toward experience and satisfaction with electroconvulsive therapy in a sample of Iranian patients". Journal of ECT. 25 (2): 106–12. doi:10.1097/YCT.0b013e31818050dc. PMID 18708944.
- ^ a b Wilkins KM et al. (March 2008). "Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature". Journal of geriatric psychiatry and neurology. 21 (1): 3–11. doi:10.1177/0891988707311027. PMID 18287164.
- ^ a b Mental Health: A Report of the Surgeon General – Chapter 4. Retrieved 2007-12-29.
- ^ Sussman, M.D., Norman (December 2006). "In Session with Charles H. Kellner, MD: Current Developments in Electroconvulsive Therapy". Primary Psychiatry 2007;14(3):34-37. Retrieved 2009-10-17.
- ^ Devanand DP, Sackeim HA et al. (July 1991). "Absence of cognitive impairment after more than 100 lifetime ECT treatments". The American Journal of Psychiatry 148 (7): 929–32. PMID 2053635.
- ^ a b Miller LJ (May 1994). "Use of electroconvulsive therapy during pregnancy". Hosp Community Psychiatry 45 (5): 444–50. PMID 8045538.[dead link]
- ^ Walker R, Swartz CM (September 1994). "Electroconvulsive therapy during high-risk pregnancy". Gen Hosp Psychiatry 16 (5): 348–53. doi:10.1016/0163-8343(94)90022-1. PMID 7995506.
- ^ Ferrill MJ, Kehoe WA, Jacisin JJ (1992). "ECT During Pregnancy: Physiologic and Pharmacologic Considerations". Convuls Ther 8 (3): 186–200. PMID 11941169.
- ^ Echevarría Moreno, M, Martin Muñoz, J, Sanchez Valderrabanos, J, Vázquez Gutierrez, T (December 1998). "Electroconvulsive therapy in the first trimester of pregnancy". The journal of ECT 14 (4): 251–4. PMID 9871846.
- ^ Pinette MG, Santarpio C, Wax JR, Blackstone J (August 2007). "Electroconvulsive therapy in pregnancy". Obstet Gynecol 110 (2 Pt 2): 465–6. doi:10.1097/01.AOG.0000265588.79929.98. PMID 17666629.
- ^ Yellowlees, PM, Page, T (1990). "Safe use of electroconvulsive therapy in pregnancy". The Medical journal of Australia 153 (11–12): 679–80. PMID 2246991.
- ^ Haskett RF and Loo C (2010) Role of Adjunctive Psychotropic Medications during ECT in the Treatment of Depression, Mania and Schizophrenia J ECT. 2010 September; 26(3): 196–20
- ^ a b c Prudic J, Olfson M, Sackeim HA (July 2001). "Electro-convulsive therapy practices in the community". Psychol Med 31 (5): 929–34. doi:10.1017/S0033291701003750. PMID 11459391.
- ^ a b Duffett R, Lelliott P (1998). "Auditing electroconvulsive therapy. The third cycle". Br J Psychiatry 172 (5): 401–5. doi:10.1192/bjp.172.5.401. PMID 9747401.
- ^ a b Lock, T (1995). "Stimulus dosing". In C Freeman (ed.) The ECT Handbook. London: Royal College of Psychiatrists, 72–87.
- ^ Committee on Mental Health (March 2002). "Report on Electroconvulsive Therapy:EXECUTIVE SUMMARY". New York State Assembly. Retrieved 8 March 2011.
- ^ See the Slovenian government website for information about ECT in Slovenia.
- ^ Motohashi N, Awata S, Higuchi T (2004). "A questionnaire survey of ECT practice in university hospitals and national hospitals in Japan". J ECT 20 (1): 21–3. doi:10.1097/00124509-200403000-00005. PMID 15087992.
- ^ Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN (2005). "Survey of the practice of electroconvulsive therapy in teaching hospitals in India". J ECT 21 (2): 100–4. doi:10.1097/01.yct.0000166634.73555.e6. PMID 15905751.
- ^ Ikeji OC, Ohaeri JU, Osahon RO, Agidee RO (1999). "Naturalistic comparative study of outcome and cognitive effects of unmodified electro-convulsive therapy in schizophrenia, mania and severe depression in Nigeria". East Afr Med J 76 (11): 644–50. PMID 10734527.
- ^ "Abusive practice of "unmodified" electroshock treatment abolished at main psychiatric facility of Turkey". Disabled Peoples' International. Retrieved 2008-03-25.
- ^ Dutta, Rita (2003). "Psychiatrists plead against ban of direct electro convulsive therapy". Indian Express Group of Newspapers. Retrieved 2007-12-31.
- ^ Rise In Electric Shock Therapy In County. Sarah Hall, Norwich Evening News 24, June 4, 2008. Accessed: June 4, 2008.
- ^ Hermann R, Dorwart R, Hoover C, Brody J (1995). "Variation in ECT use in the United States". Am J Psychiatry 152 (6): 869–75. PMID 7755116.
- ^ Cauchon, Dennis (1995-12-06). "Patients often aren't informed of full danger". USA Today.
- ^ "Electroconvulsive Therapy in Children" by Edward Shorter, Ph.D. December 1, 2013
- ^ Texas Department of State (2002) Electroconvulsive therapy reports.
- ^ Fink, M. & Taylor, A.M. (2007) Electroconvulsive therapy: Evidence and Challenges JAMA Vol. 298 No. 3, p330–332.
- ^ Pippard J, Ellam L (1981). "Electroconvulsion treatment in Great Britain 1980". Lancet 2 (8256): 1160–1. PMID 6118592.
- ^ a b Electro convulsive therapy: survey covering the period from January 2002 to March 2002. . Department of Health.
- ^ NICE 2003. Electroconvulsive therapy (ECT). Retrieved on 2007-12-29.
- ^ Carney, S; Geddes, J (2003). "Electroconvulsive therapy: recent recommendations are likely to improve standards and uniformity of use". British Medical Journal 326 (7403): 1343–4. doi:10.1136/bmj.326.7403.1343. PMC 1126234. PMID 12816798.
- ^ NICE (2003). Appraisal of electroconvulsive therapy: decision of the appeal panel. London: NICE.
- ^ Duffett, R; Lelliott, P (1998). "Auditing electroconvulsive therapy: the third cycle". British Journal of Psychiatry 172 (5): 401–405. doi:10.1192/bjp.172.5.401. PMID 9747401.
- ^ Royal College of Psychiatrists (2006). ECTAS newsletter issue 5.
- ^ Electroshocks for mentally ill patients to be banned (2011). [1] Teena Thacker
- ^ Johnson, R. "An informed consent form for electroconvulsive therapy, draft 1." (PDF). PsychRights.
- ^ Texas Legislature (2004). Health & Safety Code Chapter 578, Electroconvulsive And Other Therapies Sec.578.001.
- ^ Fergusson G (ed) "et al." (2009). "The Scottish ECT Accreditation Network (SEÁN) Annual Report 2009" (PDF). Scottish ECT Accreditation Network. Retrieved 2010-05-24.
- ^ Jones, R (1996) Mental Health Act Manual, 5th edition. London: Sweet and Maxwell, page 225.
- ^ a b c Rose D, Wykes T, Bindman J, Fleischmann P (2005)"Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy". British Journal of Psychiatry 186:54–59.
- ^ Lutchman, RD et al. (2001). "Mental health professionals' attitudes towards and knowledge of electroconvulsive therapy". Journal of Mental Health 10 (20): 141–150. doi:10.1080/09638230124779.
- ^ The Mental Health Act 1983 (updated version) Part IV, Section 58. Care Quality Commission[dead link]
- ^ Care Quality Commission (2010) ECT: Your rights about consent to treatment[dead link]
- ^ The Mental Health Act 1983 (updated version) Part IV, Section 62. Care Quality Commission[dead link]
- ^ The Mental Health Act Commission (2005) In Place of Fear? eleventh biennial report, 2003–2005, 236. The Stationery Office.
- ^ Care Quality Commission (2011) CQC says care for people treated under the Mental Health Act still needs to improve
- ^ The Mental Health (Care and Treatment) (Scotland) Act 2003, Part 16, sections 237–239.
- ^ National Institute for Health and Care Excellence
- ^ A. E. Hotchner, Papa Hemingway: A Personal Memoir, ISBN 0-7867-0592-2; pg 280
External links[edit]
- Position Statement on Electroconvulsive Therapy (ECT) [PDF] – from the American Psychiatric Association.
- MIND on ECT – information on ECT from MIND (leading mental health charity in England and Wales).
- About to have ECT? ... – Psychiatric Times article on the portrayal of ECT by Hollywood
- ECT - information from mental health charity The Royal College of Psychiatrists


text:
For grown-ups, it's a haven of bliss – for children, the city's biggest sandpit. The Kulturstrand in Bavaria's capital city is a welcome relief for all, especially city-dwellers who, according to the organisers, are always needing a holiday.
There's no plane journey, simply a dream island in the midst of the metropolitan ocean. You can meet on the square, have a chat and swap news. It's like switching from stressed urbanite to cool flaneur. Don't rush past, join in with the rest.
Right there, in a public space in the city centre, the Kulturstrand conjures holiday feelings the second it comes into view. Roads become beaches, the buzz of the city becomes the swish of the sea, traffic islands become urban atolls, is how it's seen by die urbanauten, the brains behind the beach.
There's a stage programme and a bar – everything's nice and laid-back, relaxed and chilled. In the evenings there's live music and Munich DJs, films or plays. In the daytime the children's programme turns it back into a family island – and the biggest sandpit in town.
Aktuella datum:
All information om priser, datum och öppettider med förbehåll för ändringar.
Lägg till dina favoriter här. Spara. sortera dela och skriv ut dina val och planera hela din Tysklandsresa.
0 favoriter har valts

subset: commoncrawl


text:
National Oceanic and Atmospheric Administration
From Openwaterpedia
National Oceanic and Atmospheric Administration (NOAA), pronounced like "noah", is a scientific agency within the United States Department of Commerce focused on the conditions of the oceans and the atmosphere. NOAA warns of dangerous weather, charts seas and skies, guides the use and protection of ocean and coastal resources, and conducts research to improve understanding and stewardship of the environment. In addition to its civilian employees, NOAA research and operations are supported by 300 uniformed service members who make up the NOAA Commissioned Officer Corps.
Contents |
Vision, mission, and goals
NOAA's strategic vision is "an informed society that uses a comprehensive understanding of the role of the oceans, coasts, and atmosphere in the global ecosystem to make the best social and economic decisions."
The agency's mission is "to understand and predict changes in the Earth's environment and conserve and manage coastal and marine resources to meet our nation's economic, social, and environmental needs."
In support of its vision and mission, NOAA has four goals to guide its suite of operations. Each goal corresponds to activities focusing on ecosystems, climate, weather and water, and commerce and transportation. Specifically, NOAA operates to:
- Ensure the sustainable use of resources and balance competing uses of coastal and marine ecosystems, recognizing both their human and natural components.
- Understand changes in climate, including global climate change and the El Niño phenomenon, to ensure that Americans can plan and respond properly.
- Provide data and forecasts for weather and water cycle events, including storms, droughts, and floods.
- Provide weather, climate, and ecosystem information to make sure individual and commercial transportation is safe, efficient, and environmentally sound.
Purpose and function
NOAA plays several specific roles in society, the benefits of which extend beyond the US economy and into the larger global community:
- A Supplier of Environmental Information Products. NOAA supplies information to its customers and partners pertaining to the state of the oceans and the atmosphere. This is clearly manifest in the production of weather warnings and forecasts through the National Weather Service, but NOAA's information products extend to climate, ecosystems, and commerce as well.
A Provider of Environmental Stewardship Services. NOAA is also the steward of U.S. coastal and marine environments. In coordination with federal, state, local, tribal, and international authorities, NOAA manages the use of these environments, regulating fisheries and marine sanctuaries as well as protecting threatened and endangered marine species.
A Leader in Applied Scientific Research. NOAA is intended to be a source of accurate and objective scientific information in the four particular areas of national and global importance identified above: ecosystems, climate, weather and water, and commerce and transportation.
Recognizing that it is essential that we understand the challenges that we face as part of the Earth system in order to create appropriate solutions, NOAA conducts an end-to-end sequence of activities, beginning with scientific discovery and resulting in a number of critical environmental services and products. The five "fundamental activities" are:
- Monitoring and observing Earth systems with instruments and data collection networks.
- Understanding and describing Earth systems through research and analysis of that data.
- Assessing and predicting the changes of these systems over time.
- Engaging, advising, and informing the public and partner organizations with important information.
- Managing resources for the betterment of society, economy and environment.
History and organizational structure
NOAA was formed on October 3, 1970, after Richard Nixon proposed creating a new department to serve a national need "… for better protection of life and property from natural hazards … for a better understanding of the total environment … [and] for exploration and development leading to the intelligent use of our marine resources …" NOAA formed a conglomeration of three existing agencies that were among the oldest in the federal government. They were the United States Coast and Geodetic Survey, formed in 1807; the Weather Bureau, formed in 1870; and the Bureau of Commercial Fisheries, formed in 1871. NOAA was established within the Department of Commerce via the Reorganization Plan No. 4 of 1970. With its ties to the United States Coast and Geodetic Survey, NOAA celebrated 200 years of service in 2007.
NOAA works toward its mission through six major line offices, in addition to more than a dozen staff offices:
Line Offices
The National Environmental Satellite, Data and Information Service (NESDIS) The National Marine Fisheries Service (NMFS) The National Ocean Service (NOS) The National Weather Service (NWS) Office of Oceanic and Atmospheric Research (OAR) Office of Program Planning and Integration (PPI)
Staff Offices
Office of the Federal Coordinator for Meteorology Office of Marine and Aviation Operations NOAA Central Library
National Weather Service
The National Weather Service (NWS) is tasked with providing "weather, hydrologic, and climate forecasts and warnings for the United States, its territories, adjacent waters and ocean areas, for the protection of life and property and the enhancement of the national economy." This is done through a collection of national and regional centers, and more than 120 local weather forecast offices (WFOs). They are charged with issuing weather forecasts, advisories, watches, and warnings on a daily basis. They issue more than 734,000 weather and 850,000 river forecasts, and more than 45,000 severe weather warnings annually. NOAA data is also relevant to the issues of global warming and ozone depletion. The NWS operates NEXRAD, a nationwide network of Doppler weather radars which can detect precipitation and their velocities. Many of their products are broadcast on NOAA Weather Radio, a network of radio transmitters that broadcasts weather forecasts, severe weather statements, watches and warnings 24 hours a day.
National Ocean Service
The National Ocean Service (NOS), part of the National Oceanic and Atmospheric Administration within the U.S. Department of Commerce, is focused on ensuring that ocean and coastal areas are safe, healthy, and productive. NOS scientists, natural resource managers, and specialists serve America by ensuring safe and efficient marine transportation, promoting innovative solutions to protect coastal communities, and conserving marine and coastal places.
The National Ocean Service is composed of program offices, programs, and staff offices:
Program Offices
Center for Operational Oceanographic Products and Services (CO-OPS) NOAA Coastal Services Center (CSC) National Centers for Coastal Ocean Science (NCCOS) Office of Coast Survey (OCS) Office of National Geodetic Survey (NGS) Office of National Marine Sanctuaries (ONMS) Office of Ocean and Coastal Resource Management (OCRM) Office of Response and Restoration (OR&R)
NOAA Integrated Ocean Observing System (IOOS) Program
Staff Offices
International Program Office (IPO) Management and Budget Office (M&B)
National Environmental Satellite, Data, and Information Service
The National Environmental Satellite, Data, and Information Service (NESDIS) was created by NOAA to operate and manage the United States environmental satellite programs, and manage the data gathered by the NWS and other government agencies and departments. Data collected by the NWS, U.S. Navy, U.S. Air Force, the Federal Aviation Administration, and meteorological services around the world, are housed at the National Climatic Data Center in Asheville, North Carolina. NESDIS also operates the National Geophysical Data Center (NGDC) in Boulder, Colorado, the National Oceanographic Data Center (NODC) in Silver Spring, Maryland, the National Snow and Ice Data Center (NSIDC) and the National Coastal Data Development Center (NCDDC) which are used internationally by environmental scientists.
NESDIS also runs the:
Office of Systems Development (OSD) Office of Satellite Operations (OSO) Office of Satellite Data Processing & Distribution (OSDPD) Satellite Applications and Research (STAR) formerly the Office of Research & Applications Joint Polar Satellite System Program Office GOES-R Program Office International & Interagency Affairs Office Office of Space Commercialization
The service operates and manages many geosynchronous satellites and polar orbiting satellites. In 1960 TIROS-1, NOAA's first owned and operated geostationary satellite was launched. In 1983 NOAA assumed operational responsibility for LANDSAT satellite system. In 1984 the Tropical Ocean-Global Atmosphere program (TOGA) program began.
In 1977 the Pacific Marine Environmental Laboratory (PMEL) deployed the first successful moored equatorial current meter – the beginning of the Tropical Atmosphere/Ocean (TAO) array. In 1979 NOAA's first polar-orbiting environmental satellite was launched.
Current operational satellites include: NOAA-15, NOAA-16, NOAA-17, NOAA-18 and NOAA-19 (launched 2/6/2009). [edit] National Marine Fisheries Service (NMFS) Main article: National Marine Fisheries Service
Fisheries, which was initiated in 1871 to protect, study, manage and restore fish. The NMFS has a marine fisheries research lab in Woods Hole, Massachusetts and is home to one of NOAA's five fisheries science centers.
Its law enforcement agency is the National Oceanic and Atmospheric Administration Fisheries Office for Law Enforcement based in Silver Spring, Maryland.
Office of Oceanic and Atmospheric Research
NOAA's research, conducted through the Office of Oceanic and Atmospheric Research (OAR), is the driving force behind NOAA environmental products and services that protect life and property and promote economic growth. Research, conducted in OAR laboratories and by extramural programs, focuses on enhancing our understanding of environmental phenomena such as tornadoes, hurricanes, climate variability, solar flares, changes in the ozone, air pollution transport and dispersion,[3][4] El Niño/La Niña events, fisheries productivity, ocean currents, deep sea thermal vents, and coastal ecosystem health. NOAA research also develops innovative technologies and observing systems.
The NOAA Research network consists of 7 internal research laboratories, extramural research at 30 Sea Grant university and research programs, six undersea research centers, a research grants program through the Climate Program Office, and 13 cooperative institutes with academia. Through NOAA and its academic partners, thousands of scientists, engineers, technicians, and graduate students participate in furthering our knowledge of natural phenomena that affect the lives of us all.
The Air Resources Laboratory (ARL) is one of the laboratories in the Office of Oceanic and Atmospheric Research. It studies processes and develops models relating to climate and air quality, including the transport, dispersion, transformation and removal of pollutants from the ambient atmosphere. The emphasis of the ARL's work is on data interpretation, technology development and transfer. The specific goal of ARL research is to improve and eventually to institutionalize prediction of trends, dispersion of air pollutant plumes, air quality, atmospheric deposition, and related variables.


text:
VANCOUVER -- Kevin Bieksa scored 10:18 into the second overtime as the Vancouver Canucks defeated the San Jose Sharks 3-2 Tuesday night to advance to the Stanley Cup final for the first time in 17 years.
The game was won on a strange play. The puck took a funny bounce off the back boards, and several of the Sharks were standing looking around when Bieksa fired a knuckler of shot that fooled everyone, including San Jose goalie Antti Niemi.
"I shot it. I think when the puck went in the goalie was looking behind the net," Bieksa said. "It was an ugly goal, but one I will take."
Canuck goaltender Roberto Luongo raised his stick in celebration as the rest of the team poured on the ice. Confetti fell from the roof as the sellout crowd of 18,860 chanted "we want the Cup."
"The only guy who knew where that puck was, was Kevin Bieksa and he almost fanned on it," Sharks coach Todd McLellan said. "It's one of those things you have no control over. We can talk about it all we want. There is nothing we can do about it."
The Canucks won the best-of-seven series 4-1.
"It's fantastic. It's unbelievable," Bieksa said. "To go to the Stanley Cup final is a dream come true."
Ryan Kesler scored with 13.2 seconds left in the third period to force the overtime. The gritty centre tipped a shot by Henrik Sedin past Niemi.
The Sharks outshot the Canucks 16-9 in the first overtime. Luongo kept Vancouver in the game by making a glove save of a Kyle Wellwood shot and blocking a deflection off the skate of Ian White.
Vancouver was outshot 56-34.
"I thought (Luongo) was real good," Canucks coach Alain Vigneaut said. "Tonight, without a doubt, (the Sharks) played a real strong game, probably their best game of these playoffs. We had a couple of breakdowns that he was able to keep us in the game."
The game was played exactly 17 years after Greg Adams scored in double overtime to give Vancouver a 4-3 victory over the Toronto Maple Leafs in the 1994 Western Conference final. The Canucks would lose the Stanley Cup final in seven games to the New York Rangers
The Canucks will now wait for the winner of the Eastern Conference final between the Boston Bruins and Tampa Bay Lightning. The Bruins lead that series 3-2 with Game 5 Wednesday night.
Devin Setoguchi gave San Jose a 2-1 lead with just 24 seconds gone in the third. A bouncing puck at the blue-line got past Canuck defenceman Alex Edler, giving Setoguchi and Joe Pavelski a two-man breakaway on Luongo.
Luongo rushed out of his net to try and get to the loose puck. Pavelski slid the puck under a diving Luongo to Setoguchi, who had an open net to shoot into.
Alex Burrows had the other goal for the Canucks, while Henrik Sedin had two assists.
Patrick Marleau, on the power play, also scored for the Sharks.
San Jose outshot the Canucks 25-12 after 40 minutes, but Luongo made some big saves.
In the first period Luongo stopped Sharks' captain Joe Thornton three times, once during a five-on-three San Jose power play. Thornton, playing with a suspected shoulder injury, also had a shot bank off the post behind Luongo and slide across the goal-line.
Marleau tied the game at 9:57 of the second with Bieksa off for high-sticking. Dan Boyle took a shot from the point that changed direction when it hit the glove of Vancouver defenceman Keith Ballard, then Marleau tipped it past Luongo for his eighth goal of the playoffs.
San Jose outshot Vancouver 15-6 in the opening period but still trailed 1-0.
Burrows scored his seventh goal of the playoffs at 8:02. He got the puck from a pretty tic-tac-toe passing play between Daniel and Henrik Sedin, then beat Niemi on the glove side.
The Sharks swarmed the Canuck net during a 1:24 two-man advantage, but Luongo stopped everything that was thrown at him. Thornton looked to have an open net at one point, but the big Canuck goaltender managed to stack his pads.
There were some anxious moments for Canuck fans in the second period when Kesler limped off the ice favouring his left leg and went to the dressing room. Kesler returned later in the period.
The win was a relief for the Canucks, who have struggled to finish off other series.
Vancouver is 3-4 in playoff elimination games this spring and 1-2 in Game 5s.
Vancouver took a 3-0 lead over the Chicago Blackhawks in the opening round of the playoffs, then needed a goal in overtime of Game 7 to defeat the defending Stanley Cup champions.
The Canucks were forced to make an extra trip to Nashville in the second round when they lost Game 5 of that series 4-2. They defeated the Predators 2-1 in Game 6.
The Canucks' twos trip to the final came 1982 when they lost in four straight games to the New York Islanders, and 1994, when they lost in seven games to the New York Rangers.
The Canucks won the Presidents' Trophy this year for the first time in franchise history for finishing the regular season with a league-leading 117 points. That was 12 more than the Sharks, who finished second in the Western Conference.
Notes: Defenceman Christian Ehrhoff, out with an upper body injury, and Aaron Rome, undisclosed, did not dress. ...The Canucks set an NHL playoff record by scoring three five-on-three power-play goals in Sunday's 4-2 victory. ...Sunday afternoon's game in San Jose drew an audience of 2.6 million on CBC, that was down from 3.16 million for Friday night's match. ...Canadian rocker Colin James played with The Odds on the arena video screen prior to the game.
Martin St. Louis is a Ranger, Matt Moulson is a member of the Minnesota Wild and the Montreal Canadiens have Thomas Vanek. Look back at all the big name deals that went down.
Complete Trade List
Photo Gallery: Behind the scenes at TradeCentre
Download the TSN Hockey App
Join the conversation on Twitter with #tradecentre
Get in-depth player stats, real-time on the ice matchups, Twitter Trender and so much more. Follow every play for every game.
GameTracker - Full Schedule
Are you ready for the Challenge? Select your roster of 6F, 4D and 2G each week during the regular season and you could win a new 2014 Kia Forte 5! Compete against the nation and your friends. Play Now! Play now!


text:
I would like to install wood floors in a portion of my house. I would like to run the planks in the direction shown in the attachment but I am unsure of how to continue them down the hallways (outlined in red). Would I continue the same pattern or should I turn them to run down each hallway? If I turn them how would they all tie together? Any suggestions would be appreciated. Thank you. | |||
Maybe you could do some kind of medallion or diamond pattern at the fork in the hallway, and then continue down each hall. | ||||
You really want to run the planks across the hallways at a 90 degree angle - this will tend to make the hallways look wider. Make your transition at the entry area to both hallways. Scribe a straight line from the common inner corner to the two outside corners. Continue the planking pattern from the large room into this area and then cnange to the 90 degree to hall direction. Looks like you'll have a 45 degree on one run and right around a 90 degree in the opposite direction on the other. Jaybee | ||||
For general message board help, click the tab labeled "Tools," and choose "Help" from the dropdown menu.


text:
Prosecution rests in Wacht trial
Cooperstown, ND (WDAY TV) - The jury in the Daniel Wacht murder trial could get the case as early as tomorrow. Today the prosecution rested six days after the trial started.By David Schwab, WDAZ , April 23, 2012
Further evidence revealed in day 4 of Wacht trial
Cooperstown, ND (WDAY TV) - The evidence that lead to a murder victim's severed head is shown in court during the Daniel Wacht trial.By David Schwab, WDAZ , April 20, 2012
Gruesome details emerge in day 3 of Wacht murder trial
Cooperstown, ND (WDAY TV) - In day 3 of the Daniel Wacht murder trial the State Forensic Examiner gave new details into the death of NDSU researcher Kurt Johnson. Wacht is accused of shooting and decapitated Johnson in Cooperstown on New Year's Eve 2010.By David Schwab, WDAZ , April 19, 2012
Witness says Wacht asked him to join Aryan Nation gang
Cooperstown, ND (WDAY TV) - A Grand Forks man has testified against the man accused of murdering NDSU Professor Kurt Johnson today. He says the alleged murderer asked him to join an Aryan Nation gang.By David Schwab, WDAZ , April 18, 2012
Wacht murder trial underway in Cooperstown
Cooperstown, ND (WDAY TV) - The first murder trial in Griggs County in 83 years is underway. Prosecutors say a man accused of killing an NDSU researcher told witnesses he wanted to make a statement by blowing something up or killing someone.April 17, 2012
Cooperstown man asking for suppression of testimony in murder case
Cooperstown, ND (WDAY TV) - A Cooperstown man facing murder charges is asking a judge to suppress some of his testimony.By WDAY Staff Reports , April 05, 2012
Judge denies appeal in Cooperstown murder case
Cooperstown, ND (WDAY TV) - The judge is denying the appeal of a Cooperstown man accused of killing an NDSU researcher.By WDAY Staff Reports , January 24, 2012
Wacht attorney wants evidence suppressed
Cooperstown, ND (WDAY TV) - The lawyer for a man accused of killing an NDSU researcher wants some of the evidence suppressed.By WDAY Staff Reports , December 06, 2011
Sheriff Says Search For Cooperstown Murder Victim's Body Over; Witness: Suspect Made Gang Threat
In the days before investigators believe he killed the man whose severed head was found in his basement, Daniel Wacht is alleged to have said he was planning a murder or an explosion to get notice for the Aryan Nation, an infamous white-supremacist gang.By Dave Roepke , July 08, 2011
Sheriff: No Searches Planned This Week for Body of Cooperstown Murder Victim
The Griggs County sheriff says that no aerial searches are planned this week for the body of a Cooperstown murder victim. Sheriff Robert Hook says that reports of a planned search this week for the body of Kurt Johnson are false.By WDAZ Staff Report , March 28, 2011
Crews to Continue Search for Murdered Cooperstown, ND, Man's Body
Authorities are planning another aerial search for the body of a Cooperstown man who was murdered earlier this year. 54-year-old Kurt Johnson was shot in the forehead and then decapitated.March 16, 2011
Man Charged in Cooperstown Murder Appears in Court
Daniel Wacht was escorted into Griggs County court to face a single charge of murder. Police say Wacht shot 54-year-old Kurt D. Johnson and then decapitated him.By David Schwab , January 25, 2011
Cooperstown Authorities Ask Public For Information In Murder Investigation
The Griggs County Sheriff's Office is asking for the public's help to gather information that could lead them to the body of a Cooperstown man murdered earlier this month.January 18, 2011
Authorities Suspend Search For Cooperstown Man's Body
Authorities believe 54-year-old Kurt Johnson was shot in the forehead and then decapitated. A California man is being held on murder charges in the case.January 17, 2011
Bail Denied for Man Accused of Cooperstown Murder
A California man accused of killing and decapitating a Cooperstown man will be held without bail. 30-year-old Daniel Wacht was in Stutsman County court for a bond hearing Monday.By WDAZ Staff Reports , January 10, 2011
View your ad here! Cost effective targeted advertising.
Contextual advertising starting as low as $79/month. This includes targeted ad delivery and search results!
Add your business to the Marketplace »


text:
Via Larry Brown Sports:
Some of the greatest players in the history of the NBA have worn Los Angeles Lakers uniforms. With so many Hall of Famers having hoisted championship banners for L.A., it's almost impossible to label one of them the greatest Laker of all time. Jerry West, who won an NBA title, made it to the Finals nine times and was a 14-time all star, would be in the discussion. However, West emphatically gives that title toKobe Bryant.
"What he has accomplished with this team, I don't think there's any question in my mind at this point in time – because of him being with this team for his whole career – that he has been the greatest Laker player," West told USA TODAY Sports on Thursday. "I do think he's the greatest Laker player we've ever seen.
"He has an incredible desire to win and excel, and his work ethic and his skill level are what places him among the truly great, great players we've ever had in this league."
Shaquille O'Neal dominated the playoffs and earned three NBA FInals MVP awards with the Lakers. Kareem Abdul-Jabbar took home five championship rings and three league MVP awards. Magic Johnson combined all of the aforementioned accolades, winning five NBA championships, three NBA MVPs, and three Finals MVPs. All are worthy of being in the discussion.
Kobe recently became the youngest player to ever reach 30,000 points in his career, and every one of them came in a Lakers uniform. He has won five championships and two Finals MVPs with L.A., and there's no reason he can't win a sixth. If Bryant wins a sixth ring, the Kobe vs. Michael Jordan debate may become more heated than ever. But if that day should come, there will be little debate as to who is the greatest Laker of all time.
Kobe Bryant's 30,000th point from all angles
Kobe Bryant Becomes Youngest Player in NBA History to Reach 30,000 Points
Bryant eclipses 30,000, Lakers beat Hornets
Rate Kobe Bryant's New Commercial
30,000 point milestone for Kobe Bryant
Kobe youngest to 30,000 points
Kobe Bryant By The Numbers
Looking Back On My Favorite Of Kobe's 30,000 Points
Durant outduels Bryant in win over Lakers
Kobe Bryant steals ball from Austin Rivers, throws down two-handed dunk (Video)
Kevin Durant: Kobe Bryant's an 'old fart'
Houston Rockets radio announcer Craig Ackerman disses Lakers with "poopy pants" joke (Video)
Awesome Los Angeles Lakers PhotoShop
Latest Rumors | The Backyard | |||
Today's Best Stuff |
For BloggersJoin the Yardbarker Network for more promotion, traffic, and money. |
Company Info |
Help |
What is Yardbarker?Yardbarker is the largest network of sports blogs and pro athlete blogs on the web. This site is the hub of the Yardbarker Network, where our editors and algorithms curate the best sports content from our network and beyond. |


text:
I think I nailed it at another site a few weeks ago.
Google is being left alone in the name of a free Internet. Whether Google is "evil" or not is less the question than the fact that Google, the Internet's most powerful player, is American.
What people fail to understand, still, is that Google (GOOG) represents the largest player in the Internet infrastructure space. It is a global version of what AT&T (T) was 30 years ago. And it's not just subject to American law, it represents American values better than any government-run service could.
The FTC ruling upsets Microsoft (MSFT) but this is not about Microsoft. Microsoft made its mistake in lobbying U.S. policymakers, demanding that they do something about Google's monopoly on search, preventing it from expanding that monopoly into other areas.
That wasn't really the issue. The issue was whether the U.S. would have a strong, private company dominating the global Internet infrastructure, driving it forward, and driving America's values on the Internet forward. It's not about Google vs. Microsoft, but Google vs. Baidu, Google vs. Alibaba, and Google vs. whatever other local, national Internet company may rise up in the Arab world or in India or in Africa, anywhere America wants influence.
So what do we have? Google will stop abusing the patents it won from Motorola that are essential to standards. Google will open the application program interfaces, or APIs, to its AdWords platform. Google will let sites opt out of having extracts in its index, and let them limit themselves to headlines or page headers.
There are small wins here for European newspapers, who can now limit their ability to be found on Google News, and for Internet advertisers, who can now more effectively game Google's ad systems. There are small wins here for Apple (AAPL), which effectively neutered Google's patent attacks on its own gear, and for competitors who feared their sites would be lost under links to Google's competing offerings.
But these are concessions Google can easily give. The company knows it has maximized its advantages in vanilla search, and in Web advertising, and is now working in other areas - in selling cloud services and building its own computing platforms. They will not impact the bottom line at all.
If Microsoft is wondering why the FTC didn't go after Google the way the Department of Justice did it back in the day, the answer is simple. The FTC concluded that the Department of Justice was too successful against Microsoft, that its antitrust action caused Microsoft to bind itself up in layers of bureaucracy, lawyers and PR flacks constantly saying no, and that if we did that to Google America's interests in a free Internet would be irreparably harmed.
Google is essential to America's foreign policy in the 21st century. That's why it won.


text:
Download Preview | Edit or add effects |
by lineartestpilot, Stock Photo 29113769
art, artwork, black and white, camping, cartoon, character, cute, doodle, drawing, funny, hand drawn, illustration, line, lowbrow, quirky, retro, silly, tent, thinking, thought balloon, thought bubble, thought cloud, traditional, vector
Made with love in NYC.
Bigstock and Big Stock Photo are registered trademarks of Shutterstock. Bigstockphoto is a trademark of Shutterstock.
© 2004-2014 All rights reserved - Bigstock®


text:
Riding toy, 6-volt battery and charger
With real working lights and sounds, the Peg-Perego John Deere Battery Powered Utility Tractor is certain to be a favorite for any boy or budding tomboy. The folks at Peg Perego know how to enchant a toddler, and this great riding toy is a prime example of that knowledge. The included backhoe is an awesome addition that greatly enhances the opportunity for creativity and play, and the automatic brakes and low top speed make sure the child enjoys it safely. A 6-volt battery and charger is included, 2AA batteries to operate lights and sounds are not included. Great for ages 2 to 4.
About Peg Perego
After the birth of his infant son in 1949, Giuseppe Perego was unhappy with the minimal selection of juvenile products and decided to design his own baby carriage. His wife added beautiful, functional fabrics, and the overall aesthetics caught the attention of other parents in the Peregos' small Italian neighborhood. They were inundated with requests by neighbors for carriages of their own, and Peg Perego was born. Before long, the company was introducing high chairs, strollers, and other juvenile products. With each new product, the family commitment to quality continued. Always thinking forward, Peg Perego has never rested on past products or designs; it continues to stay current with parents' changing needs and new research that highlights the health and safety of infants and juveniles.
Weight Capacity
55 lbs.
1 Year (Vehicle) , 6 Months (Battery)
Assembly Required
Adjustable Seat , Sound
Overall Dimensions
48.5L x 19.5W x 23.5H inches
Battery Size
6 Volt
John Deere
Our products are shipped ready to assemble. Assembly is easy and requires only common household tools. Furniture will be shipped with all necessary hardware. Assembly is a matter of minutes with easy to follow instructions. Carefully read the instructions and acquaint yourself with the parts and hardware before starting assembly of your furniture.
by PowerReviewsPros
Best Uses
Reviewed by 7 customers
Sort by
Displaying reviews 1-5
Previous | Next »
Best Uses
Comments about Peg-Perego John Deere Battery Powered Utility Tractor:
We love this tractor. Our grandson is really a little too young for it being 19 months old. This summer it should be perfect for him. He really couldn't understand how to use the power pedal.But he loved climbing on and off of it in the house Christmas day. He was happy just doing that. He also loved working the bucket up and down.
Best Uses
Comments about Peg-Perego John Deere Battery Powered Utility Tractor:
I looked everywhere and this was the only place I could get this on time for my son's birthday and luckily enough, it was the most reasonably priced! Thanks!!
Best Uses
Comments about Peg-Perego John Deere Battery Powered Utility Tractor:
We had it put together in a short amount of time. It is so cute, can not wait till my grandson see it.
Best Uses
Comments about Peg-Perego John Deere Battery Powered Utility Tractor:
This was the first time I ordered from hayneedle.com it was fast and easy and the product I purchased as a gift arrived two days before expected!!! I will definately use them again!!!
Best Uses
Comments about Peg-Perego John Deere Battery Powered Utility Tractor:
My grandson is tractor crazy and now he has one just like grandpas
Displaying reviews 1-5
Previous | Next »
Have a question about this product? Ask a Product Expert! The answer will be emailed to you and then posted here.