Impotentie brengt een constant ongemak met zich mee, net als fysieke en psychologische problemen in uw leven https://zonder-voorschrift.com/cialis-zonder-recept.html terwijl generieke medicijnen al bewezen en geperfectioneerd zijn
¿Está buscando comprar Cialis en línea en España? Es importante asegurarse de que el sitio web que elija sea legítimo y seguro antes de realizar una compra. En comprar-farmacia.es, ofrecemos una amplia selección de medicamentos de calidad, incluido Cialis, para tratar la disfunción eréctil (DE).
Nuestro sitio web es fácil de usar y está diseñado para garantizar una experiencia de compra en línea segura y satisfactoria. Trabajamos con farmacias acreditadas y ofrecemos envío rápido y discreto para su comodidad.
También puede contar con nosotros para la privacidad de sus transacciones en línea. En comprar-farmacia.es, utilizamos tecnología de encriptación de datos de última generación para garantizar que sus transacciones sean seguras y privadas.
Si tiene preguntas o necesita ayuda para realizar un pedido, nuestro equipo de atención al cliente está disponible para ayudarlo en todo momento. Nos tomamos en serio su privacidad y solo ofrecemos medicamentos de alta calidad y auténticos.
Visite nuestro sitio web en comprar-farmacia.es para obtener más información sobre nuestros productos y servicios. Asegúrese de que su compra en línea de Cialis sea segura y confiable eligiendo comprar-farmacia.es como su farmacia en línea de confianza en España.
03-23-artaloytia.fm
Negative Signs and Symptoms Secondary to Antipsychotics: A Double-Blind, Randomized Trial of a Single Dose of Placebo, Haloperidol, and Risperidone in Healthy Volunteers Juan Francisco Artaloytia, M.D. Objective: Despite the clinical observa-
tion that antipsychotics can produce neg-
Celso Arango, M.D.
ative symptom scales: the Subjective Def-
icit Syndrome Scale total score and an an-
this action in healthy subjects. The present
Adrienne Lahti, M.D. Javier Sanz, M.D. Ana Pascual, M.D.
chiatric Rating Scale (BPRS), the SANS, the
Method: The authors used a double-
blind, placebo-controlled trial of single
Pedro Cubero, M.D.
score, and the analog scale for subjective
done (2.5 mg) in normal subjects. Thirty-
drowsiness, risperidone but not haloperi-
David Prieto, M.Sc.
than placebo on the BPRS and the SANS. Tomás Palomo, M.D.
after 3–4 hours and subjective negativesymptoms and drowsiness after 24 hours. Conclusions: Single doses of both halo- Results: N ei t he r o f t he a ct i ve dru gs (Am J Psychiatry 2006; 163:488–493)
Since the therapeutic effects of antipsychotics were been applied to address this issue. On one hand, primary
first discovered, it has been clear that they produce unde-
negative symptoms have been defined as observer-rated
sirable as well as target effects, some of which are difficult
negative symptoms that cannot be explained by positive
to distinguish from the negative symptoms of schizophre-
symptoms, depressive symptoms, or antipsychotic-pro-
nia (1–5). Motor side effects can mimic negative symp-
duced motor extrapyramidal symptoms. Statistical tech-
toms, as well as nonmotor type effects, including indiffer-
niques have evolved from simpler, correlational, and cova-
ence, apathy, and avolition. These effects have been more
riant strategies (11–13) to more sophisticated ones, such
frequently described in patient self-reports than in obser-
as path analysis (8, 9, 14). The unexplained variance is in-
vations made by clinicians. These drug-induced side ef-
terpreted as a direct treatment effect on primary negative
fects are difficult to distinguish from primary or othersources of secondary negative symptoms (6, 7).
symptoms. However, there are also other sources of sec-ondary negative symptoms, and nonmotor effects of an-
Both first- and second-generation antipsychotics re-
duce negative symptom ratings in schizophrenia. Several
tipsychotics could be considered primary negative symp-
studies (8, 9) have reported higher efficacy in negative
toms. Therefore, to deal with this, some investigators use a
symptoms with second-generation antipsychotics than
clinically defined and rated condition called the “deficit
with haloperidol; however, the differential effect may be
syndrome.” To be categorized as such, all known sources
lost when low doses of haloperidol are used (10).
of secondary negative symptoms have to be ruled out, and
The effect of antipsychotics on primary negative symp-
the negative symptoms have to be long-lasting, with a lon-
toms is more controversial. Two general approaches have
ARTALOYTIA, ARANGO, LAHTI, ET AL.
Negative symptoms are easy to measure in schizophre-
way to rate motor extrapyramidal symptoms, in correlation with
nia patients but difficult to attribute to a precise source. To
dopamine D2 receptor occupancy (25).
clarify these ambiguities, we studied healthy subjects free
Observer-Rated Negative Symptoms
of any psychiatric symptoms. We assessed all negative
Negative symptoms were assessed with 1) the Brief Psychiatric
symptoms in healthy subjects in response to single doses
Rating Scale (BPRS) (26) negative symptoms subscale and 2) the
of haloperidol or risperidone in a double-blind, placebo-
Scale for the Assessment of Negative Symptoms (SANS) (27) alo-
controlled trial. We quantified the subjective experiences
gia and affect flattening items. Alogia and affective flattening were
of treated individuals as well as the observed effects. Ac-
selected from the other items because they appear in several fac-
cording to our hypothesis, haloperidol would cause the
tor analyses in the negative syndrome, and they do not require afull week of observation. Instead of referring to illness during the
most negative symptoms as measured by observer-rated
interview, because the participants did not have schizophrenia,
and subjective measures and placebo the least.
they were asked to talk about their most recent holidays. Both ofthe raters were psychiatrists (J.F.A. and J.S.). Interrater reliability
scores (intercorrelation coefficients) for the two raters on thesescales were between 0.80 and 0.92 for each BPRS item, each of thetwo SANS items, and the Simpson-Angus Rating Scale and Barnes
Subjects
Rating Scale for Drug-Induced Akathisia total scores. All four in-
The subjects were recruited from advertisements placed in the
terviews (baseline and after administration of the placebo and
Hospital Universitario 12 de Octubre in Madrid and met the fol-
the two drugs) were videotaped, and the raters made a consensus
lowing criteria: ages 18 to 60 years, no psychiatric disorder ac-
rating after watching the taped interviews.
cording to the Structured Clinical Interview for DSM-IV for nor-mal volunteers, not receiving psychotropic drugs, no drug or
Subjective Negative Symptoms
alcohol abuse or dependence (except for nicotine), and no other
The Subjective Deficit Syndrome Scale was applied (28). This
relevant medical condition. The hospital’s ethical committee for
scale asks subjects to rate, from 0 to 4, aspects regarding lack of
research with humans approved the research protocol. Written
energy, blunted affect, and difficulty in or altered thinking, in-
informed consent was obtained from all subjects after we fully ex-
cluding, “Do you tire easily (complaints about excessive fatigue)?”
“Have you lost the ability to feel emotions (apathy)?” “Do youhave problems concentrating (subjective problems with concen-
Design
tration)?” An analog scale (29) of subjective negative symptoms
A within-subject design was carried out with haloperidol and
was also developed based on Huber’s basic symptoms (30) (the
risperidone. Each participant was interviewed and rated four
scale is available upon request from the first author). Both scales
times. The first interview established baseline variables (with
handwriting and a videotaped interview). The subsequent threeinterviews were identical and were performed after double-blind
Drowsiness
random assignment of the sequence with which placebo, halo-
This concept is defined on the basis of Lewander’s consider-
peridol, and risperidone were to be administered.
ation of sedation, which distinguishes between a more generalsomnolence effect versus a more lethargic effect (4). An analog
Procedure
scale (29) was developed to measure the sedative or somnolent
Because of ethical considerations, only single low doses of the
effect. These scales present a line with two ends; each end ex-
substances were administered in liquid formulations of placebo,
presses a specific maximum and minimum for the variable being
haloperidol (5 mg), or risperidone (2.5 mg). Water and lemon ex-
evaluated. The subject is asked to make a mark on the line repre-
tract were added to the substances to ensure double-blind condi-
senting how he or she feels. (The scale is available upon request
tions (18). The 2.5-mg dose of risperidone was chosen as the
from the first author.) This variable was considered a possible
equivalent of 5 mg of haloperidol (19, 20).
confounding factor in the rating of observer-rated and self-rated
The baseline assessments were repeated at two different time
points. The first evaluation (clinician-rated scales) was made atthe time the substances reached their highest plasma level (T
Data Analysis
Tmax for haloperidol is 1.7–6.1 hours (21); it is 0.8 hour (SD=0.3)
A balanced crossover experimental design was used, with the
for risperidone, and 3.2 hours (SD=1.5) for its active metabolite 9-
three treatments and six possible sequences of administration to
hydroxyrisperidone (22). Therefore, ratings were performed be-
address the issue of treatment order. Five individuals were ran-
tween 3 and 4 hours after administration for the first assessment.
The second assessment (self-rated scales) was performed 24
Data were analyzed as usual in this type of design with re-
hours after administration and assessed cumulative subjective
peated-measures analysis of variance (ANOVA) and treatment
experiences over the previous 24 hours. The minimum washout
and order of administration as fixed factors. The overall null hy-
period between administrations was 48 hours based on half-lives
pothesis (placebo=haloperidol=risperidone) was tested for each
of haloperidol (14.5–36.7 hours) (21), risperidone (mean=2.8
outcome measured by using a continuous variable. If this null hy-
hours, SD=0.5), and 9-hydroxyrisperidone (mean=20.5 hours,
pothesis was rejected, pairwise tests of the differences between
treatments (haloperidol versus placebo, risperidone versus pla-cebo, and risperidone versus haloperidol) were then performed
Motor Signs
with Student’s t test with Bonferroni correction. When the out-
Parkinsonism and akathisia were evaluated with standardized
come was measured with a noncontinuous variable (Barnes Rat-
scales: the Simpson-Angus Rating Scale (23) and the Barnes Rat-
ing Scale for Drug-Induced Akathisia, the Simpson-Angus Rating
ing Scale for Drug-Induced Akathisia (24), respectively. Handwrit-
Scale, or the SANS), only pairwise comparisons were made be-
ing was evaluated as another variable of motor outcome. De-
cause the number of observations was insufficient to guarantee
creased handwriting area has been described as a more precise
the requirements of the overall test. NEGATIVE SYMPTOMS IN HEALTHY SUBJECTS TABLE 1. Descriptive Characteristics of 32 Healthy Subjects Given Placebo, Haloperidol, and Risperidone Individually
Barnes Rating Scale for Drug-Induced Akathisia
Scale for the Assessment of Negative Symptoms
a Negative handwriting values meant larger letters than positive handwriting values. TABLE 2. Differences Between Treatments in Motor Signs and Negative Symptoms of 32 Healthy Subjects Given Placebo, Haloperidol, and Risperidone Individuallya
a ANOVA was not applied to the Simpson-Angus Rating Scale or the SANS. No analysis was performed for the Barnes Ratings Scale for Drug-
Induced Akathisia because only three patients rated a 1 on this scale (two subjects taking haloperidol and one taking risperidone).
A significance level of 0.05 was established. Some outcomes
shown in Table 1 and Table 2. As for motor symptoms, one
that might be affected by drowsiness, specifically observer- and
subject reported acute buccolingual dystonia 20 hours af-
self-rated negative symptoms, were included in the model as co-
ter receiving haloperidol. No significant differences were
variates. To rule out any possible confounding effect of other epi-demiological variables (gender, age, smoking status, level of edu-
detected between drugs for the Simpson-Angus Rating
cation, or body mass index), we applied ANOVA and chi-square
Scale score or the handwriting area. No analysis was per-
tests to be sure that they were not correlated with the sequence of
formed for the Barnes Rating Scale for Drug-Induced
Akathisia because only three patients rated a 1 on thisscale (two subjects taking haloperidol and one taking ris-
peridone). The participants taking risperidone scored sig-
Thirty-two subjects entered the study. Thirty subjects
nificantly higher on the BPRS negative symptoms sub-
completed it; one person dropped out voluntarily,
scale than those receiving placebo; likewise, th e
whereas another was eliminated after suffering a hypoten-
individuals receiving haloperidol or risperidone scored
sive episode with risperidone. Of the completer group, 17
significantly higher on the SANS items versus those re-
were women and 13 were men; the mean age was 32.4
ceiving placebo. The participants taking haloperidol or
years (SD=10.5, range=18–58). Ten of the completers were
risperidone scored significantly higher on the two self-
smokers. Mean education in years was 17.1 (SD=1.6,
rated scales than those receiving placebo (Table 1 and Ta-
range=12–18). Body mass index was 24.7 kg/m2 (SD=7.1,
ble 2). The subjects scored significantly higher on drowsi-
range=18.8–38.1). The variables were homogeneously dis-
ness after taking either haloperidol or risperidone versus
tributed in the different groups and randomly assigned to
those receiving placebo; in a comparison of the two
the different sequences of drug administration. No signifi-
drugs, they scored higher with risperidone than with ha-
cant differences attributable to the order of administra-
loperidol (Table 1 and Table 2). After control for drowsi-
tion were detected for any of the variables.
ness, only those taking risperidone scored significantly
Descriptive characteristics and differences between
higher than those receiving placebo on the BPRS and
treatments, before and after control for drowsiness, are
SANS negative symptom items (Table 2). ARTALOYTIA, ARANGO, LAHTI, ET AL.
toms by different second-generation antipsychotics. Inthese studies, antipsychotic-induced “nonmotor” nega-
tive symptoms could have been considered primary nega-
tive symptoms. The estimates of effect size for the medica-
tion-induced negative symptoms found in the present
study could be useful in evaluating findings from pharma-
cological trials of agents that target negative symptoms.
Some authors (4) give definitions for unspecific seda-
tion (drowsiness) and specific sedation (Rifkin’s akinesia,
which we have called negative signs and symptoms sec-
ondary to antipsychotics) that clearly differentiate themconceptually. Nonetheless, we find it complicated to dis-tinguish between them in this manner. In fact, in thepresent study, subjective negative symptoms scales couldnot clearly distinguish between drowsiness and negative
signs and symptoms secondary to antipsychotics. The in-
formation provided by these scales must be questioned
until they can distinguish more clearly between these two
factors. This idea receives strong support from data fromvarious authors and clinical descriptions. The point is
clarified further by Laborit’s description:
The patients required less analgesics and, at the
same time, had an unusual state of consciousness in
that they were readily aroused but seemed uncon-
cerned with the environmental situation. (1)
and by an unprompted written report by one of our sub-
I feel slow but not sleepy. During the interview I feel
clumsy, and I want to finish as soon as possible (it’sdifficult for me to explain what is happening to me). Discussion
Drowsiness was also used as a possible confounding fac-
The results of the current study indicate that single-dose
tor in the rating of observer-rated negative symptoms
administration of both haloperidol and risperidone pro-
scales (BPRS and SANS). Albeit to a lesser degree than the
duces negative symptoms in healthy volunteers, accord-
“subjective” scales in our study, these scales were also af-
ing to both clinician-rated and self-report scales. Neither
fected to the point of rendering insignificant the difference
of the drugs produced significant motor extrapyramidal
between haloperidol and placebo. However, the differ-
symptoms, as measured by the Simpson-Angus Rating
ences between risperidone and placebo remained signifi-
Scale or the handwriting area, based on the findings of this
cant. Drowsiness is hardly ever controlled in the statistical
single-dose study. Negative symptoms were found in the
approaches used to demonstrate the effect of drugs on pri-
absence of a detectable motor extrapyramidal compo-
mary negative symptoms. Moreover, high doses of benzo-
nent. In the case of risperidone, negative symptoms were
diazepines can provoke drowsiness, and this factor might
also independent of a sedative effect.
be confounded with observer-rated negative symptoms.
Treatment-induced nonmotor negative symptoms are
An interpretation of the differences between haloperi-
not taken into account in studies in which primary nega-
dol and risperidone depends on their equivalent doses.
tive symptoms are defined as observer-rated negative
Several studies have suggested that the doses chosen in
symptoms that cannot be explained by positive, depres-
the present study were equipotential. The 1997 APA guide-
sive, and motor symptoms (8, 9, 14). Because our normal
lines (19) indicated that a 1–2-mg dose of risperidone
comparison subjects lacked any initial psychopathology,
equals a 2-mg dose of haloperidol and that haloperidol
the drug-induced nature of these symptoms is clear. Thus,
may require doses double those of risperidone. Schotte et
we can say that the symptoms are “nonmotor” negative
al. (20) measured the occupancy of central neurotransmit-
symptoms secondary to antipsychotics. In the studies
ter receptors by haloperidol and risperidone in an ex vivo
cited (8, 9, 14), unexplained variance is interpreted as a di-
quantitative autoradiography. Doses of 0.048 mg/kg of ha-
rect treatment effect exerted on primary negative symp-
loperidol and 0.11 mg/kg of risperidone were needed to
NEGATIVE SYMPTOMS IN HEALTHY SUBJECTS
induce 25% D2 receptor occupancy in the caudate-puta-
for research in schizophrenia. Psychiatry Res 1989; 30:119–
men. However, other studies have supported equivalent
8. Tollefson GD, Sanger TM: Negative symptoms: a path analytic
approach to a double-blind, placebo- and haloperidol-con-
Our study group consisted of healthy individuals receiv-
trolled clinical trial with olanzapine. Am J Psychiatry 1997; 154:
ing single doses of antipsychotics. The effect of antipsy-
chotics in patients with schizophrenia may differ from
9. Möller HJ: The negative component in schizophrenia. Acta Psy-
that seen in this study with normal comparison subjects.
The study was conducted with a single dose, and the effect
10. Rosenheck R, Perlick D, Bingham S, Liu-Mares W, Collins J, War-
ren S, Leslie D, Allan E, Campbell EC, Caroff S, Corwin J, Davis L,
of these antipsychotics on the variables assessed could
Douyon R, Dunn L, Evans D, Frecska E, Grabowski J, Graeber D,
change in chronic settings. Nevertheless, both a review of
Herz L, Kwon K, Lawson W, Mena F, Sheikh J, Smelson D, Smith-
the literature and clinical experience support the finding
Gamble V (Department of Veterans Affairs Cooperative Study
that antipsychotics produce negative signs and symptoms
Group on the Cost-Effectiveness of Olanzapine): Effectiveness
secondary to antipsychotics, not only in healthy subjects
and cost of olanzapine and haloperidol in the treatment ofschizophrenia: a randomized controlled trial. JAMA 2003; 290:
as shown in the present study but also in schizophrenia
patients in long-term treatment. A further limitation was
11. Tandon R, Goldman R, DeQuadro JR, Goldman M, Perez M, Jib-
that a benzodiazepine arm was not included, which would
son M: Positive and negative symptoms covary during cloza-
have made it possible to compare the purer sedative effect
pine treatment in schizophrenia. J Psychiatr Res 1993; 27:341–
and the neuroleptic effect caused by the antipsychotics.
Drowsiness and subjective negative symptoms were as-
12. Miller D, Arndt S, Andreasen NC: Negative symptoms in anti-
psychotic-naive schizophrenics and the effect of haloperidol
sessed by self-rated scales 24 hours after drug administra-
tion to detect all symptoms that appeared during the en-
13. Lieberman JA, Safferman AZ, Pollack S, Szymanski S, Johns C,
tire 24-hour period. However, the observer-rated negative
Howard A, Kronig M, Bookstein P, Kane JM: Clinical effects of
symptoms and motor variables were measured after 3–4
clozapine in chronic schizophrenia: response to treatment
hours. Correction for those variables with another variable
and predictors of outcome. Am J Psychiatry 1994; 151:1744–
evaluated at a later time point could be a potential con-
14. Peralta V, Cuesta MJ, Martinez-Larrea A, Serrano JF: Differenti-
founding factor. Finally, the dose chosen might have fa-
ating primary from secondary negative symptoms in schizo-
vored risperidone versus haloperidol, because although
phrenia: a study of neuroleptic-naive patients before and after
some reports stated that risperidone is equivalent to halo-
treatment. Am J Psychiatry 2000; 157:1461–1466
peridol, we used half the dose of risperidone for compari-
15. Kirkpatrick B, Buchanan RW, Ross DE, Carpenter WT Jr: A sepa-
rate disease within the syndrome of schizophrenia. Arch GenPsychiatry 2001; 58:165–171
16. Breier A, Buchanan RW, Kirkpatrick B, Davis OR, Irish D, Sum-
Received Sept. 5, 2004; revisions received Dec. 4, 2004, and May 17,
merfelt A, Carpenter WT Jr: Effects of clozapine on positive and
2005; accepted May 27, 2005. From the Hospital Universitario 12 de
negative symptoms in outpatients with schizophrenia. Am J
Octubre, Madrid; the Department of Psychiatry, Hospital General Uni-versitario Gregorio Marañón; the Maryland Psychiatric Research Cen-
ter, University of Maryland School of Medicine, Baltimore; and the De-
17. Buchanan RW, Breier A, Kirkpatrick B, Ball P, Carpenter WT Jr:
partment of Health Sciences, Universidad de Alcalá, Madrid. Address
Positive and negative symptom response to clozapine in
correspondence and reprint requests to Dr. Arango, Departamento
schizophrenic patients with and without the deficit syndrome.
de Psiquiatría, Hospital General Universitario Gregorio Marañón, C/
Ibiza, 43, 28009 Madrid, Spain; carango@mce.hggm.es (e-mail).
18. Supplementary Drugs and Other Substances. London, Pharma-
The authors thank Brian Kirkpatrick, M.D., for his comments on a
ceutical Press (Royal Pharmaceutical Society of Great Britain),
19. American Psychiatric Association: Practice Guideline for the
Treatment of Patients With Schizophrenia. Am J Psychiatry
References
1. Campan L, Lazorthes G: [The origin and success of neurolep-
20. Schotte A, Janssen PF, Megens AA, Leysen JE: Occupancy of cen-
tics.] Ann Anesthesiol Fr 1976; 17:1021–1024 (French)
tral neurotransmitter receptors by risperidone, clozapine and
2. Rifkin A, Quitkin F, Klein DF: Akinesia: a poorly recognized
haloperidol, measured ex vivo by quantitative autoradiogra-
drug-induced extrapyramidal behavioral disorder. Arch Gen
21. Kudo S, Takashi I: Pharmacokinetics of haloperidol. Clin Phar-
3. Goldberg E: Akinesia, tardive dysmentia, and frontal lobe dis-
order in schizophrenia. Schizophr Bull 1985; 11:255–263
22. He H, Richardson JS: A pharmacological, pharmacokinetic and
4. Lewander T: Neuroleptics and the neuroleptic-induced deficit
clinical overview of risperidone, a new antipsychotic that
syndrome. Acta Psychiatr Scand 1994; 89(suppl 380):8–13
blocks serotonin 5-HT2 and dopamine D2 receptors. Int Clin
5. Awad AG: Subjective response to neuroleptics in schizophre-
23. Simpson GM, Angus JWS: A rating scale for extrapyramidal side
6. Carpenter WT Jr, Heinrichs DW, Wagman AM: Deficit and non-
effects. Acta Psychiatr Scand Suppl 1970; 212:11–19
deficit forms of schizophrenia: the concept. Am J Psychiatry
24. Barnes TRE: A rating scale for drug-induced akathisia. Br J Psy-
7. Kirkpatrick B, Buchanan RW, McKenney PD, Alphs LD, Carpen-
25. Kuenstler U, Juhnhold U, Knapp WH, Gertz HJ: Positive correla-
ter WT: The Schedule for the Deficit Syndrome: an instrument
tion between reduction of handwriting area and D2 dopamine
ARTALOYTIA, ARANGO, LAHTI, ET AL.
receptor occupancy during treatment with neuroleptic drugs.
drome Scale. Compr Psychiatry 1990; 31:216–226
Psychiatry Res Neuroimaging 1999; 90:31–39
29. Luria RE: The validity and reliability of the visual analogue
26. Ventura J, Lukoff D, Nuechterlein KH: Appendix 1: Brief Psychi-
mood scale. J Psychiatr Res 1975; 12:51–57
atric Rating Scale Expanded Version (4.0) scales, anchor points,
30. Koehler K, Sauer H: Huber’s basic symptoms: another ap-
and administration manual. Int J Meth Psychiatr Res 1993; 3:
proach to negative psychopathology in schizophrenia. Compr
27. Andreasen NC: Modified Scale for the Assessment of Negative
Symptoms (SANS). Iowa City, University of Iowa, 1984
31. Remington G, Kapur S, Zipursky R: APA practice guideline for
28. Jaeger J, Bitter I, Czobor P, Volavka J: The measurement of sub-
schizophrenia: risperidone equivalents (letter). Am J Psychiatry
jective experience in schizophrenia: the Subjective Deficit Syn-
Although finer distinctions could be drawn, how aboutI suspect that the definition of eras differs somewhat according toone’s purposes. Yes, and this is where it gets really interesting. I have been reading On the Natural History of Destruction By W.G. Se-bald, essays on the reluctance of Germans to remember and discuss the Alliedbombings of Nazi Germany. Sebald is a unique voice. Reading hi
SPECIAL ONE TIME SETTLEMENT SCHEME (OTS) FOR NPA ACCOUNTS IN MSME SECTOR Coverage of the Scheme • The approved policy will also cover eligible cases in which the Bank has initiated actions under SARFAESI Act, cases pending before Courts/ DRTs /Lok Adalat and decreed accounts subject to obtaining consent decree from the Court/ DRT/ Lok Adalat. • The approved OTS scheme will cover