Vikram J Anand

• Consultant surgeon
• Kalra Hospital and Sri Ram Cardio-Thoracic
• & Neurosciences Centre,
• New Delhi, India
• Supervisor for postgraduate surgical studies
• The National Board of Examinations,
• New Delhi, India
• Surgical tutor and examiner
• The Royal College of Surgeons of Edinburgh,
• Scotland, UK
• Professor of surgery and former director,
• department of surgery
• Maulana Azad Medical College and
• Associated Hospitals, New Delhi, India

Avoid arguing children as well as to parents or care provider may help over food choices impotence medication discount vimax 30caps. Note: Childhood obesity with associated long-term physical and psychological effects is a potential concern regardless of current weight erectile dysfunction va form purchase vimax in india. Collaborative Establish a nutritional plan (with moni to ring erectile dysfunction prostate purchase 30 caps vimax otc, when needed) Certain medical conditions erectile dysfunction doctors long island purchase vimax now. Review labora to ry studies impotence with antihypertensives discount vimax 30caps with visa, such as serum albumin or prealbu Indica to rs of nutritional health and effects of nutrients in organ min erectile dysfunction hernia purchase vimax with amex, transferrin, amino acid profile, iron, blood urea nitrogen function. Refer for dental hygiene care, nutritional counseling, or May be needed to provide assistance, support, and direction psychiatric or family therapy, as indicated. Refer to home-care resources when indicated by specific Assists with initiation and supervision of home nutrition therapy condition or illness. Initiate safety precautions as individually appropriate, such Preventing injuries and complications is a prime responsibility as bed in low position, padded side rails, infection pre of parents and caregivers. Moni to r medication administration closely, paying careful Provides for effective therapeutic management, prevents attention to allergies, dosage measurements and conver overdose, and reduces risk for to xic reactions. Review home situation for safety hazards, especially when Provides opportunity for teaching about fac to rs that could pro child has sustained some type of injury related to unsafe mote a safer home environment, or might identify need for home environment. Provide written resources for parent or caregiver and age Provides information for later review and self-paced learning. Collaborative Refer to home-care assistance, medical supplies, community Can provide additional opportunities for support for child safety, safety and education programs, and resources, such as for improving parenting skills, and obtaining necessary Family Effectiveness Training, as indicated. Affects ability to to lerate fluctuations in fluid level and ability to respond to fluid needs. Moni to r vital signs; color of palms, soles of feet, and mucous Indica to rs of hydration status. Note: Hypotension indicative of membranes; weight; skin turgor; breath sounds; urinary and developing shock may not be readily observed in child until gastric output; and hemodynamic measurements. Determine whether child has problems with urination, such as Evaluation of these issues is important for determining cause urine retention, bed-wetting, burning, or holding. Because smaller volumes are administered, close moni to ring and regulation is required to prevent fluid overload while correcting fluid balance. Replace electrolytes, as indicated, by oral route whenever Replacement solutions formulated for children are often safer possible. Note: Child with mild dehydration not caused by trauma may respond well to oral rehydration starting with 5 to 10 mL by mouth every 15 to 20 minutes and increasing according to to lerance. Arrange with labora to ry to combine common tests and draw Excessive or repetitive blood draws may markedly reduce Hgb smallest amount of blood that is necessary to perform and Hct levels in pediatric client. Determine cultural and religious influences on parenting and this information is crucial to helping the family identify and de expectations of self and child. Note attachment behaviors between parent and child(ren), rec Lack of eye contact and to uching may indicate bonding prob ognizing cultural background. Failure to bond effectively with newborn is thought to and spend time with child, particularly newborn or infant. Note presence and effectiveness of extended family support Provides role models for parent(s) to help them develop own systems. However, parents are important, chil use of home care and respite services, as appropriate. As a rule, when parents take care of themselves, their coping abilities are enhanced and they are better parents. Note: Siblings also require time with parents to attend to their needs and to have positive interactions. Discuss issues of stepparenting and ways to achieve positive Blending two families can be a very demanding task, and pre relationships in a blended family. Providing information and/or role models can help people learn to negotiate and develop skills for parenting and living to gether. Temperature may be measured orally, rectally, and at the axillary space, with rectal measurement being on aver age approximately 1 degree higher than oral, and axillary being 1 degree lower than oral. Newborn is more vulnerable to heat loss than older child because of body surface area, higher metabolic rate, and sensitivity to environmental conditions. Provide safety precautions, as Higher fevers may trigger febrile seizures in susceptible children. Apply cool cloth to Limiting linens and use of room fan can help lower body head and bathe in lukewarm bath. Collaborative Administer antipyretics, for example, acetaminophen (Tylenol) Some degree of fever may be useful for fighting infection; how 10 to 15 mg/kg every 4 hours or ibuprofen (Motrin) 10 to ever, excessive levels may have adverse effects and require 15 mg/kg every 6 hours, as indicated. Note: Financial issues, such as being under or uninsured, having high insurance co-pays, or a lack of transportation may restrict ability to follow through on needed or routine care. Allows for incorporating existing strengths or limitations and assistance in adapting and organizing care, as necessary. Provide for communication and coordination between the health Promotes continuity of care and continuation of goals. Determine Additional education or problem-solving may be required for causes for deviations. Iden Provides for prevention of complications and early intervention tify signs and symp to ms requiring further evaluation and in times of illness. Collaborative Make referral as needed for community support services such Provides for child care and parental support in home setting to as homemaker, skilled nursing care, well-baby clinic, and enhance coping with therapeutic regimen. Body fluid is composed primarily of water and electrolytes keep the composition and volume of body fluids within and is divided in to two types. The interventions are page 184 presented in a general format for inclusion in the primary plan of care. Provide information about condition, prognosis, and treat ment needs, as appropriate. Fluid balance: State in which the volume of body water and its Hypovolemia: Decreased circulating volume in the intravascular solutes (electrolytes and nonelectrolytes) are within normal compartment; also known as fluid deficit or dehydration. Rel limits and there is normal distribution of fluids within the ative and absolute hypovolemic states can commonly coexist intracellular and extracellular compartments. A client who is relatively Fluid volume deficit: Imbalance in fluid volume in which there hypovolemic may have adequate volume; however, it does not is loss of fluid from the body not compensated for by an ade remain or exist in the intravascular space. Absolute hypovolemia is fluid intake and (2) excessive fluid loss from vomiting; diar considered to be measurable fluid (greater than 500 mL/day). Fluid volume excess: Overabundance of water in the interstitial Intracellular fluid: Portion of to tal body water with its dissolved fluid spaces or body cavities (edema) or an excess of fluid solutes within the cell membranes. The colloid osmotic pressure is and increased capillary permeability; (3) increased venous pres influenced by proteins. This is due to the proteins being the sure, as in congestive heart failure, thrombophlebitis, and cir only dissolved substance in the plasma and interstitial fluid rhosis of the liver; and (4) retention of sodium due to increased that do not diffuse readily through the capillary membrane. Positive fluid balance: Fluid gain is greater than fluid loss, which Hypervolemia: Increase in the volume of circulating blood; might suggest a problem with either the renal or cardiovascular also known as fluid overload or fluid excess. Excess sodium intake: sodium-containing foods, medications, cites, major abdominal surgery, malnutrition, or protein or fluids (orally/intravenously); excessive or rapid administra depletion tion of hyper to nic or, possibly, iso to nic parenteral fluids d. The most common cause of decreased plasma transport substances and water throughout the body. Albumin albumin levels is related to inflamma to ry processes, including helps maintain intravascular pressure. More than half of the hemodilution, loss of extravascular space, increased consump protein in blood serum is albumin. Normal adult May be elevated if dehydration is result of osmotic diuresis fasting range is 70 to 99 mg/dL. Concen in the urine may be elevated because it is elevated in the trations may mirror blood levels or be the opposite. It may also be elevated in the urine when the body is values are not fixed; kidneys vary rate of excretion to match losing to o much sodium. If blood sodium levels are low due to dietary intake (Matheny, 2012), but generally range from insufficient intake, then urine concentrations will also be low. Adventitious sounds (crackles) and extra heart sounds (S3) are indicative of fluid excess, possibly resulting in rapid devel opment of pulmonary edema. Edema can be either a cause or a result of various pathological conditions reflecting four competing forces: blood hydro static and osmotic pressures and interstitial fluid hydrostatic and osmotic pressures. The dynamic interaction of these four forces allows fluid to shift from one body compartment to an other. Note decreased urinary output and Decreased renal perfusion, cardiac insufficiency, and fluid positive fluid balance on 24-hour calculations. If fluids are restricted, set up a Fluid restrictions, as well as extracellular shifts, can aggravate 24-hour schedule for fluid intake. Moni to r infusion rate of parenteral fluids closely; administer Rapid fluid bolus or prolonged excessive administration poten via control device, as necessary. Gravity improves lung expansion by lowering diaphragm and shifting fluid to lower abdominal cavity. Turn or reposition, and promote early ambulation, where Reduces pressure and friction on edema to us tissue, which is possible. Schedule care to provide frequent rest Limited cardiac reserves result in fatigue and activity in to ler periods. Provide safety precautions as indicated, such as use of side Fluid shifts may cause cerebral edema and changes in rails, bed in low position, frequent observation, and soft mentation, especially in the geriatric population. Restraints must be used as infrequently as possible, and be limited to a specified time period with client under close supervision (Dugdale, 2012). Refer to listing of predisposing and contributing fac to rs to determine treatment needs. Restrict fluids, as If serum proteins are low because of malnutrition or gastroin indicated. Administer diuretics: loop diuretic such as furosemide (Lasix), To achieve excretion of excess fluid, either a single thiazide di thiazide diuretic such as hydrochlorothiazide (Esidrix), or uretic or a combination of agents may be selected, such as potassium-sparing diuretic such as triamterene (Direnium), thiazide and spironolac to ne. Potassium deficit may occur, especially if client is receiving potassium-wasting diuretic. May be done to rapidly reduce fluid overload, especially in the presence of severe cardiac or renal failure. Levels may be higher than normal if sodium trations may mirror blood levels or be the opposite. Older adults (who are more likely to have serious and chronic conditions than young people) are at increased risk for de hydration, one of the most frequent causes of hospitaliza tion in adults ages 65 to 75 (Russo, 2012). Additional risk fac to rs for dehydration include female gender, more than four chronic conditions, more than four medications, immo bility, and laxative use (Post, 2011). Palpate peripheral pulses; note capillary refill and skin color, Conditions that contribute to extracellular fluid deficit can re turgor, and temperature. Measure or estimate fluid losses from Fluid replacement needs are based on correction of current all sources such as gastric losses, wound drainage, and deficits and ongoing losses. Measure Although weight gain and fluid intake greater than output may edema to us areas such as abdomen and limbs. Turn frequently, gently massage skin, and protect bony Tissues are susceptible to breakdown because of vasoconstric prominences. Bathe every other day using mild Skin and mucous membranes are dry with decreased elasticity soap. Provide safety precautions, as indicated, such as use of side Decreased cerebral perfusion frequently results in changes in rails where appropriate, bed in low position, frequent mentation or altered thought processes, requiring protec observation, and soft restraints if required.

G Signs that need urgent assessment include spontaneous bruising erectile dysfunction treatment can herbal remedies help cheap vimax 30 caps free shipping, any bleeding that is difficult to arrest erectile dysfunction killing me vimax 30 caps with amex, and any evidence of gastrointestinal bleeding erectile dysfunction treatment over the counter purchase vimax online. What advice would you give a patient who had cut himself shaving and who was concerned that the bleeding did not s to p for a few minutesfi Questions should include: G Have there been any recent changes in her medication (eg impotence of organic origin meaning buy genuine vimax line, a course of antibi otics)fi This section looks at the main risks associated with the use of anticoagulants and introduces the concept of safety indica to rs to audit anticoagulant services erectile dysfunction doctor mumbai cheap vimax online master card. It is important to be able to demonstrate the quality of a service erectile dysfunction exercises treatment buy generic vimax 30caps, to manage the risks within a service, and to continually moni to r a service to ensure that standards are maintained or improved when failures or lapses are identified. In order to manage and minimise these risks it is essential to define standards of care and to regularly audit the care of patients on anticoagulants. Training and work competences Healthcare staff who prescribe, adjust the dosage, dispense, prepare, administer, moni to r and discharge patients on anticoagulant therapy must receive adequate training and have the necessary work competences to undertake their duties safely. Procedures and clinical pro to cols Your local healthcare trusts should have written procedures and clinical pro to cols for the safe use of both oral and injectable anticoagulant therapies. These documents should be based on the guidelines for anticoagulant therapy that have 7,9,10 been published by the British Society of Haema to logy Standards Taskforce. Moni to ring these indica to rs will help to identify risks and promote appropriate action to reduce risks. Using your incident reporting system, analyse the percentage of errors with warfarin and identify any common causes. A clinical audit in one hospital trust found that intravenous drug users on oral anticoagulant therapy were poorly managed due to issues of non-compliance and ongoing injection of drugs. Percentage of patients following a loading pro to col appropriate to indication for anticoagulation. Percentage of patients in therapeutic range at discharge (for inpatients being transferred to outpatient care). Percentage of patients that were not issued with patient held information and written dose instructions at start of therapy. Percentage of patients lost to follow up (and risk assessment of process for identifying patients lost to follow up). If possible, medicines should be selected that do not produce clinically significant interactions. If this is not possible, the prescriber, who initiates or discontinues a prescription for an interacting medicine, is responsible for ensuring that the patient is informed that an interacting medicine has been commenced or discontinued. The patient should be instructed to provide details of the change in therapy when the blood sample is taken. This information can then be recorded on the test request form to inform the anticoagulant clinic. When dispensing a new medicine or noting the discontinuation of an interacting medicine you must check that the additional safety precautions have been taken. Standardised methods of medicine product supply and dosage adjustment the wide variations in the methods of supply and dosing for warfarin tablets leads to complexity and confusion for patients, carers and healthcare professionals alike. Patient and carer groups have reported that they would prefer warfarin regimens to have the following characteristics: G to use the least number of tablets each day G to use constant daily dosing and not alternate day dosing G not to require the use of half tablets. Safe practice procedures for anticoagulants in care homes the safe use of oral anticoagulants in social care settings requires particular mention. This includes care homes and when homecare workers support patients in their own homes. The use of anticoagulants in National minimum standards for care homes and domiciliary care agencies require moni to red dosage systems providers to have written policies and procedures for medicines. Verbal dose changes should only be used in emergencies, and always confirmed in writing as soon as possible. There is widespread use of moni to red dosage systems in care homes and in the community at large. Although the use of these systems may be beneficial for other types of medicines, where dose changes are infrequent, the use of anticoagulants in these dosage systems is not recommended. These systems are usually not flexible enough to facilitate frequent dose changes. It is recommended that oral anticoagulants are administered from the original packs dispensed for individual patients. There may be some patients in the community, outside of care home settings, that use compliance aids to help them manage their medicines. Oral anticoagulants may still be used in these compliance aids provided that whoever fills these aids ensures that the tablets in the compliance aid matches the latest prescribed dose. G Anticoagulants are one of the classes of medicines that are most commonly associated with fatal medication errors. Identify how clinical governance in your workplace will help you to overcome some of the problems associated with the management of anticoagulants. Understand the procedures that must take place when co-prescribing interacting drugs with warfarin. What additional precautions must be taken when an interacting drug is prescribed with warfarinfi This section completes the learning programme by taking a brief look at the various service models for providing anticoagulant services and the role of pharmacists and technicians in improving anticoagulant control. Outpatient anticoagulant clinics based in hospitals are well established, but attending them is an inconvenient and time-consuming process for many patients; in addition, hospital-based services are struggling to cope with an increasing workload. Hospital pharmacists have increasingly become involved in the provision of anticoagulant services over a number of years. To improve ease of access to this service some pharmacists are already involved in moni to ring warfarin in a variety of primary care settings. There are many advantages to pharmacist-led anticoagulant clinics in primary care (see page 90 for the relevant resources). These include: G patient convenience G continuity of care G maintenance of accurate patient records G identification of drug interactions G identification and minimisation of adverse effects. And, of course, the introduction of supplementary and independent prescribing means that pharmacy will have an even bigger role to play in the future. Practice point Are any pharmacists in your area involved in providing anticoagulation servicesfi However, the availability of these self-testing kits enables patients to moni to r and adjust their own treatment. In addition, the guidelines highlight a number of gaps that currently prevent a safe and effective roll-out of such technology to patients. G To improve access to anticoagulant services some pharmacists are already involved in moni to ring warfarin in a variety of primary care settings. G There are many advantages to having pharmacist-led anticoagulant clinics in primary care. However, the evidence suggests that patient self-testing and the self-management of oral anticoagulation is an option for a minority of patients only. Intended outcomes By the end of this section you should be able to : Learning objective Well can youfi Appreciate why alternative service models for anticoagulant clinics are urgently needed. Outline how pharmacy can support patients taking anticoagulants and the advantages of pharmacy-led anticoagulation clinics in primary care. How would you like to extend the service and what are the associated training requirementsfi Who would you initially involve from both primary and secondary care when setting up a pharmacist-led anticoagulant clinic in your localityfi British Medical Association and the Royal Pharmaceutical Society of Great Britain (2008). Venous thromboembolism: Reducing the risk of thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. Recommendations from the British Committee for Standards in Haema to logy and National Patient Safety Agency. An evidence-based review and guidelines for patient self-testing and management of oral anticoagulation. Further reading Clinical guidelines/evidence-based reviews G Clinical knowledge summary on the management of atrial fibrillation and deep vein thrombosis. British Journal of Haema to logy 133 (1): 19-34 G British Committee for Standards in Haema to logy (1998). Hospital Pharmacist 13 (6): 205-210 For advice on setting up an anticoagulant clinic G British Committee for Standards in Haema to logy (1998). British Journal of Haema to logy 101 (2): 374-387 G Coleman B, Patterson D, Long M and Farrell J (2003). Pharmaceutical Journal 270 (7238): 308-311 G the enhanced service specification under the new pharmacy contract on anticoagulation moni to ring is available at. Comparative effectiveness of general practitioner versus pharmacist dosing of patients requiring anticoagulation in the community. Primary Care Pharmacy 1 (3): 70-72 Background articles from the Pharmaceutical Journal (referred to in Section 2. This may provide evidence to your primary care trust or commissioning body about your ability to deliver an anticoagulant moni to ring service. I can describe how an anticoagulant moni to ring service fits in to government health policies and pharmacy modernisation 3. I can summarise the main contraindications, cautions and side-effects of warfarin therapy 5. I can evaluate the benefits and risks of anticoagulation in different patient groups. I can describe how warfarin therapy is initiated and illustrate the different types of induction regimen. I can demonstrate an understanding of the main fac to rs affecting warfarin therapy. I understand the important role of the pharmacy team in informing and educating patients about warfarin therapy. I can advise and educate patients taking warfarin on the implications of travel, surgery and visiting the dentist. I am able to identify the signs of excessive anticoagulation in patients taking warfarin. I can list five clinical governance measures that relate specifically to an anticoagulant moni to ring service. I can describe and provide evidence of clinical governance processes to support a quality anticoagulant moni to ring service and help overcome some of the problems associated with the management of anticoagulants. I have put processes in place to train my pharmacy team with regard to certain aspects of managing patients taking anticoagulants to enable them to actively participate in the implementation/delivery of this service. I am able to operate the software and interpret the results from the computerised clinical decision support system. Recruit family & friends to make donations Dive In to Action and swim laps for pledges, jump cannonballs for cash, or make your own Swim challenge! Kimberly Goodrich, Contributing Writer John Masino, Advertising Manager S to ries to Inspire By Shawn Feliciano. This material is intended for general informational pur poses only, and it does not constitute medical advice. For 2011 diagnosis and treatment options, you are urged to consult your physician. No part of this publication may be reproduced, s to red in a retrieval system, or trans A portion of this magazine has mitted in any form or by any means, electronic, mechanical, pho to copying, record been printed on recycled paper using soy-based ink. These important initiatives have been in development for the past year, and I appropriately for the spring season, have recently come to fruition. Please be sure to visit trainer in strategic planning for the Peter our new website often! Examples of this type of pain include musculoskeletal pain, lower-back pain, painful spasms, pain related to urinary-tract infection, pain of pressure sores, and even pain associated with disease-modifying drugs. The over burning, tingling, or tightening sensation, stimulated nerves need to be calmed, and this usually occurring in the legs and arms, but may best be accomplished with anti-epileptic sometimes in the body; it is the most drugs, tricyclic antidepressants, and common chronic pain syndrome; it can be antispasticity drugs, to treat painful spasticity dull, nagging, or have a prickling sensation and spasms. Topical medications such as associated with warmth; it tends to be lidocaine gel or Zostrix (capsaicin to pical worse at night and after exercise; it is also analgesic) may help reduce the burning and aggravated by changes in temperature tingling. More information about specific syndromes include: treatments is provided later in this section.

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Leisure-time physical activity and alcohol consumption were the most important life-style fac to rs predicting all sleep complaints erectile dysfunction world statistics order generic vimax line, except snoring erectile dysfunction pills free trial buy vimax online from canada. The effects of physical activity and alcohol consumption differed for different shift schedules diabetes and erectile dysfunction causes cheap 30caps vimax amex. The researchers concluded that different shift systems erectile dysfunction in young guys buy generic vimax 30caps online, also 2 shift work and permanent night work erectile dysfunction instrumental generic vimax 30 caps on line, increase the frequency of sleep complaints erectile dysfunction doctors austin texas buy cheap vimax 30caps on line. Especially 3-shift work seems to interact with life-style fac to rs by increasing the adverse effects and decreasing the beneficial effects on sleep and sleepiness. Actually nodding off or falling asleep behind the wheel within the last year occurs for a sizeable proportion of the populations (range 10% up to 40%). Adolescents need more sleep than adults and fatigue may affect youngsters more than adults. Fatigue and road crashes In studying fatigue and road crashes, researchers first have to find out what accidents are likely related to fatigue. The next step is to apply these definitions to existing databases and estimate the frequency of fatigue-related crashes. Research that informs us about the frequency of fatigue related crashes is not yet scientific proof that fatigue directly leads to risk. The ultimate aim would be to quantify the exact relationship between fatigue state and crash risk. To do this research needs to control for other fac to rs that may influence the relationship between fatigue and risk such as kilometres driven. Below we describe how to recognise fatigue-related crashes, the frequency of these crashes, and the evidence concerning the fatigue-risk relationship. Unlike the situation with alcohol-related crashes, no blood, breath, or other measurable test is currently available to quantify levels of sleepiness at a crash site. Thus current understanding of typical crash related characteristics come largely from inferential evidence. For example in the Netherlands, the combined primary cause of a crash that is attributed to sleep/illness occurs in about 1% of all registered crashes. Also, most drivers will be reluctant to admit that they were very tired or had fallen asleep at the time of the crash. In addition, the crash itself would have made most of the symp to ms of fatigue disappear. Based on these methods, estimates of the percentage of sleep-related crashes vary greatly, but often are in the range of 10-25 percentage points higher than can be concluded from police reports. The higher percentages have been found particularly in studies that have examined lorry crashes and/or fatal crashes. Based on findings from a survey study amongst 4600 male car drivers in England, Maycock [70] concluded that fatigue played a role in 9-10% of all crashes. This percentage was higher for mo to rways (20%) than for roads inside urban areas (7%) or for other roads outside urban areas (14%). A naturalistic driving study unobtrusively registers the actual driving behaviour of drivers who drive their own cars to destinations of their own choosing without an experimenter present. A naturalistic observation study may link the outward signs of fatigue (such as closed eyes) to real driving behaviour. The 100-Car Naturalistic Driving Study is an instrumented vehicle study designed to collect a large volume of naturalistic driving data over an extended period of time. The researchers installed instruments and sensors in 100 vehicles that were then driven as ordinary vehicles by ordinary drivers for one year. Drivers were given no special instructions, no experimenter was present, and the data collection system was unobtrusive. The study collected data on 15 police-reported and 67 non-police reported crashes, 761 near crashes (situations requiring a rapid, severe evasive manoeuvre to avoid a crash) and 8,295 incidents (situations requiring an evasive manoeuvre occurring at less magnitude than a near crash). In this study, fatigue was judged to be a contributing fac to r in approximately 12% of crashes, 10% of near-crashes, and 7% of crash-relevant conflicts [29]. Fatigue was measured by an observer rating of drowsiness, measured on a scale from 0 to 100 in increasing severity of drowsiness. The scale was based on the Wierwille and Ellsworth [109] rating system for driver fatigue. This rating system is based on observable personal characteristics such as facial to ne, eye blinks, eye closures, head movements, staring, lack of activity, eye expression etc. In an in-depth study, Horne and Reyner [49] established that about 20% of crashes on mo to rways were sleep-related. This study looked at single vehicle crashes under good weather and road circumstances on road segments without intersections. This is probably an underestimation since collisions with other vehicles that satisfied the Horne/Reyner criteria were not taken in to account. In Germany, a similar in-depth crash study established that about 24% crashes on a German mo to rway had to do with fatigue [63]. In Finland, all fatal road accidents are investigated in-depth by multidisciplinary investigation teams. Based on a literature study involving both in-depth and questionnaire studies, Amundsen & Sagberg [1] found that fatigue was a contributing fac to r in 15 to 20% of truck crashes. For example, it could be that drivers who are more fatigued also drive more kilometres than other drivers so that the risk per kilometre is the same for fatigued and non-fatigued drivers. Often increased risk of particular groups such as young drivers or professional drivers derives from a combination of fac to rs. Several studies have investigated the relationship between driver fatigue and crash risk and have attempted to quantify the risk increase. Reviewing these studies, Connor et al [21] concluded that nearly all studies were limited in their ability to establish a causal relationship. Study limitations concerned design, biases, and in many cases, small sample sizes. Despite these limitations the better quality cross-sectional studies do suggest a positive relationship between fatigue and crash risk. In a case control study of New Zealand drivers, Connor et al [20] compared 571 crash involved drivers with 588 non-crash involved drivers driving in the same area and at the same times. Taking in to account possible confounding variables (gender, age, socio-economic status, annual kilometres, speed, road type), they found a strong relationship between acute fatigue (based on loss of sleep the night before) and crash involvement. Crash risk was eight times higher for drivers with a score fi 4 on the Stanford Sleepiness Scale (95% confidence interval 3. In a case-control study, Cummings et al [23] compared crash-involved drivers with a similar group of non-crash involved drivers at the same location, direction, time and day. They found the crash risk was fourteen times higher for drivers who had reported to have almost fallen asleep behind the wheel (95% confidence interval 1. Studies of professional drivers (bus, lorry, truck) show that it takes around 9 or 10 hours of driving, or 11 hours of work, before crash risk starts to rise [68]. The effect of task duration is practically always entangled with the effects of the time of day and sometimes also with the length of time awake and previous lack of sleep. Short trips can also end up in fatigue-related crashes because time of day and long and irregular working hours are stronger predic to rs of fatigue than time spent driving [15][114]. The association of non medical (lifestyle) determinants of fatigue with crash has not been the subject of thorough research. There is still a lack of knowledge concerning the contribution of increasing to tal hours of work, and shift schedules to driver fatigue. Whereas research in to fatigue and sleep apnoea in truck drivers has led to awareness of these problems and some modification of work conditions [34][73][77], occupationally induced fatigue in potentially much larger numbers of commuters has received little attention. The increased risk may results from a mix of biological, lifestyle, and work-related fac to rs. For teenage drivers, the strong biological need for sleep and going out in weekend-nights may combine to increase fatigue and risk [38]. For professional drivers and long distance drivers, both reduced sleep and long working hours combine to increase fatigue and risk [53][76][91]. Stutts et al [102] investigated both situational fac to rs and individual differences in fatigue related traffic risk. The database consisted of police accident reports and surveys from 312 drivers who fell asleep at the wheel, and surveys from 155 drivers who had caused an accident as a result of fatigue. The study used as a control group 529 drivers, who were responsible for an accident, which was not caused by fatigue and 407 accident-free drivers. The researchers found that drivers responsible for a fatigue related accident had more often several jobs, were shift workers or had unusual working hours. In addition, these drivers reported to sleep less hours at the average, to feel more tired during the day, to drive more often at night-time and to have experienced drowsiness at the wheel more frequently. In comparison to drivers with accidents without fatigue origin, these drivers drove on average longer, were awake more time, slept less at night and used barbiturates more often. The authors conclude, that the crash risk due to fatigue is significantly increasing, if the driver sleeps less than 7 hours. Compared to driver averaging 8 hours of sleep or more, drivers who sleep less than 5 hours per night on average are 6 times as likely to be involved in a fatigue related crash (versus not being in a crash at all). Risk groups Specific groups of drivers engage more frequently in fatigued driving and thus have a higher risk of being involved in a fatigue-related crash. According to reviews, groups of drivers that have a higher risk to be involved in a fatigue-related crash are young drivers (< 25 years); professional drivers; long-distance drivers; shift workers; drivers with sleeping disorders [75]. Within the general group of young drivers, teenagers may be even more susceptible to effects of sleep loss than young adults. Several studies found that young drivers, and males in particular, were the most likely to be involved in fall-asleep crashes [88][49][71][9]. For example, Akerstedt & Kecklund [9] studied the fac to rs associated with involvement in early-morning crashes (from midnight to 6 am), controlling for driving exposure. They reported that the highest risk for early-morning crashes was for younger drivers. Their crash risk at this time was at least five times higher than their risk when driving at other times. In a simula to r study, Otmani et al [85] found that young professional bus and coach drivers had more difficulty to drive in a low traffic condition and felt sleepier during low traffic driving in the late evening than middle-aged professional drivers. In practice, the particular job demands of long-haul transport industry often interfere with normal rest. World-wide transport industry work practices include working long hours, prolonged night work, working irregular hours, little or poor sleep, and early starting times. Many truck drivers work more than 12 hours per day, of which at least 60% is usually spent driving [17]. These long hours of work may result in drivers obtaining less than the necessary 7 to 8 hours of sleep and cause fatigue [17]. French research in to lorry driver working times and habits showed that risk levels vary with three key fac to rs as regards the general problem of fatigue [39][40][41][18]. There is an increased risk of crashes at night, an increased risk the greater the length of the working day, and also with irregular working hours. Research points to an increased crash risk the greater the number of hours driven. However, studies show different results concerning the length of driving time needed before risk increases. Mackie & Miller [68] found some aspects of driving performance deteriorated after 8 to 9 hours driving. They analysed 750 truck crashes which clearly involved driver fatigue or were single vehicle crashes (which made it very likely they were driver fatigue related). They found twice the probability of a crash in the second half of a trip, as compared to the first half of the trip, and the odds of a crash started to rise after 5 hours driving. Folkard [36] under to ok a meta analysis of several studies of hours of driving and crash risk. Folkard found that there was a rise in likelihood of a crash at two hours in to the trip before risk dropped back to starting levels at 4 hours in to the trip.

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Tobacco: Lung cancer, chronic obstructive pulmonary disease, reactive airways, pneumonia, bronchitis, pulmonary hypertension, interstitial lung disease, pneumothorax. Injection drug use: Pulmonary hypertension, talc granuloma to sis, septic pulmonary embolism, pneumothorax, emphysema, needle embolization. Renal Alcohol: Hepa to renal syndrome, rhabdomyolysis and acute renal failure, volume depletion and prerenal failure, acidosis, hypokalemia, hypophosphatemia. Cocaine: Rhabdomyolysis and acute renal failure, vasculitis, necrotizing angiitis, accelerated hypertension, nephrosclerosis, ischemia. Sleep Alcohol: Apnea, periodic limb movements of sleep, insomnia, disrupted sleep, daytime fatigue. Trauma Alcohol: Mo to r vehicle crash, fatal and nonfatal injury, physical and sexual abuse. Musculoskeletal Alcohol: Rhabdomyolysis, compartment syndromes, gout, saturnine gout, fracture, osteopenia, osteonecrosis. Appropriateness for Buprenorphine Evaluation Questions Treatment To thoroughly evaluate a patient for appro priateness for opioid addiction treatment with Several issues should be considered in eval buprenorphine, the physician should ask the uating whether a patient is an appropriate following questions: candidate for buprenorphine treatment of opioid addiction in the office or other 1. Candidates for buprenorphine treatment should have a First, a candidate for buprenorphine treat ment for opioid addiction should have an diagnosis of opioid dependence. Bupre objectively ascertained diagnosis of opioid norphine treatment is not indicated for addiction (compulsive use of opioids despite other disorders. Are there current signs of in to xication ence as defined in the latest edition of the or withdrawalfi In rare instances, a patient may be opioids or other drugs as well as for the physiologically dependent on opioids and risk of severe withdrawal. In such a case, a short contraindication to buprenorphine course of buprenorphine may be considered treatment. Is the patient interested in bupre Second, a candidate for buprenorphine norphine treatmentfi Does the patient understand the risks (or to naloxone if treating with the bup and benefits of buprenorphine treat renorphine/naloxone combination) mentfi Physicians must review the review of treatment options safety, efficacy, side effects, potential Patients who request treatment with bup treatment duration, and other fac to rs renorphine to achieve abstinence from all with each patient. Patients who have significant psychiatric conditions, psychosocial untreated psychiatric comorbidity are stability, comorbid substance use less-than-ideal candidates for office disorders, and other fac to rs. Is the patient willing and able to follow psychiatric assessment is indicated for safety proceduresfi If a patient is all patients who have significant unwilling or unable to follow safety psychiatric comorbidity. Psychiatric procedures, or is dismissive of them, comorbidity requires appropriate then that patient is not a good candidate management or referral as part of for office-based treatment with treatment. Does the patient agree to treatment maintained on antipsychotic or mood after review of the optionsfi If a patient is ment before it is pregnant or is likely to become pregnant initiated. Treat during the course of treatment, bupre treatment for opioid ment options norphine may not be the best choice. Patients with of opioid addiction ments) and their alcohol abuse or dependence, whether associated risks continuous or periodic in pattern, may and benefits be at risk of overdose from the combi should be nation of alcohol with buprenorphine. Is the combination of sedative-hypnotics the patient actively suicidal or with buprenorphine. Use of other multiple previous treatments or medications, such as those metabolized relapses, or is the patient at high risk by the cy to chrome P450 3A4 system for relapse to opioid usefi Does the patient have medical prob relapses may not be an appropriate lems that are contraindications to candidate for office-based buprenor buprenorphine treatmentfi A complete his to ry and physical problems and relapse triggers, as well as assessment must address any medical his or her skills in managing cravings problems or physical illnesses, and and controlling impulses to use drugs. Has the patient had prior adverse ment engagement should be addressed at reactions to buprenorphinefi Supportive acute and chronic hypersensitivity to relationships and resources will increase Subutex have been reported both in the likelihood of successful treatment. Motivation is a angioneurotic edema, and anaphylactic dynamic quality that can be enhanced shock have been reported. A his to ry of hypersen the Stages of Change Readiness and sitivity to naloxone is a contraindication Treatment Eagerness Scale to Suboxone use. Is the patient taking other medications motivated individuals are more appro that may interact with buprenorphinefi Is the patient actively suicidal or homicidal; has he or she recently attempted suicide or homicidefi Does the patient exhibit emotional, behavioral, or cognitive conditions that complicate treatmentfi Is the patient currently dependent on benzodiazepines, barbiturates, or other sedative-hypnoticsfi Does the patient have a his to ry of multiple previous treatments or relapses, or is the patient at high risk for relapse to opioid usefi Does the patient have medical problems that are contraindications to buprenorphine treatmentfi Moni to ring for therapeutic plasma levels of seizure medications should be considered. Metabolism of buprenorphine and/or the Seizures antiretroviral medications may be altered when they are combined. In some cases, Buprenorphine should be used cautiously in therapeutic blood levels may need to be patients who are being treated for seizure disorders. Note that this is a caution, not a concurrently with antiseizure medications contraindication; successful treatment of. Buprenorphine is a treatment for opioid addiction, not for addiction to other classes Hepatitis and Impaired of drugs. Although the use of other drugs Hepatic Function tends to be a predic to r of poor adherence, other drug use is not an absolute contra Pharmacotherapy with buprenorphine is not indication to buprenorphine treatment. Very few studies exist on the use of bup Patients who use or abuse more than one renorphine in substance present unique problems and may pregnant women. A recent drug pregnant during use his to ry and a to xicology screen for be a predic to r of the course of drugs of abuse are guides to help assess use, treatment with abuse, and dependence on opioids and other buprenorphine, drugs. In the United States, (especially in overdose) has been reported to methadone is the standard of care for be associated with deaths (Reynaud et al. If 46 Patient Assessment treatment with buprenorphine and sedative or other sedative-hypnotic substances. Physi commonly used pharmacological treatments cians must assess for use, in to xication, and for seizures caused by alcohol or other withdrawal from sedative-hypnotics. Unfor sedative-hypnotic withdrawal, should be tunately, the use of certain benzodiazepines used only with caution in combination with and other sedatives may not be detected buprenorphine because of the increased risk on routine drug screens. Summary Alcohol Because alcohol is a sedative-hypnotic drug, Patients who may be good candidates for patients should be advised to abstain from opioid addiction treatment with buprenor alcohol while taking buprenorphine. Rarely phine are those who have an objective are individuals with active, current alcohol diagnosis of opioid addiction, who have the dependence appropriate candidates for appropriate understanding of and motiva office-based buprenorphine treatment. This effectively de to xify the patient from alcohol chapter has provided information on the while concurrently starting buprenorphine questions, cautions, and contraindications [e. Buprenorphine will not control steps in providing treatment with buprenor seizures caused by withdrawal from alcohol phine for opioid addiction. Patient Assessment 47 48 4 Treatment Pro to cols Overview In this Office-based treatment of opioid addiction has been unavailable in the Chapter United States since the early 1900s. As a consequence, physicians often treat substance-related disorders Maintenance Treatment. With the introduction of buprenorphine, office-based physicians now will have the ability to Opioid De to xification treat both the complications of opioid addiction and opioid addiction With Buprenorphine itself. At each stage of the process, many different fac to rs must be considered if the physician is to provide comprehensive and maximally effective opioid addiction care. Before initiating buprenorphine treatment, physicians should obtain a signed release of information (see Title 42, Part 2 of the Code of Federal Regulations [42 C. The chapter begins with a discussion of some general issues regarding treatment with buprenorphine. The consensus panel recommends that the Although controlled trials have not compared buprenorphine/naloxone combination be used buprenorphine monotherapy to the for induction treatment (and for stabilization buprenorphine/naloxone combination for and maintenance) for most patients. In addition, on either the monotherapy formulation or the patients who desire to change from long-acting combination formulation and did not report opioids. Physicians will be inducted using need to find their own comfort level with the buprenorphine induction pro to cols, but the consensus panel monotherapy. When the buprenorphine monotherapy initiating buprenorphine treatment, it is likely formulation is used for induction, it is that patients will feel that they are experi recommended that it be used for no more than encing the early stages of withdrawal when 2 days before switching to the buprenorphine/ they present for buprenorphine induction naloxone combination formulation (for treatment, unless they are on maintenance patients who are not pregnant). If a patient has early symp addiction: (1) opioid maintenance treatment, to ms of withdrawal, then the opioid recep to rs and (2) medically supervised withdrawal are unlikely to be occupied fully; precipitated (de to xification) with either opioid. Because opioid-assisted mainte buprenorphine in alleviating withdrawal nance and medically supervised withdrawal symp to ms can be assessed more easily. Therefore, decide arbitrarily on the length of treatment physicians must be careful when timing at initial evaluation. For about potential side effects from buprenor example, in one report of rapid-term opioid phine overdosing (especially in combination de to xification using buprenorphine, it was with benzodiazepines) or underdosing. Before undertaking bupre switched to maintenance treatment within the norphine treatment of opioid addiction, 10-day study (Vignau 1998). Thus, as treat physicians should be familiar with the signs, ment progresses, it may become a more symp to ms, and time course of the opioid appropriate time to assess the duration of withdrawal syndrome. For doses requiring the use of more counseling and/or a structured rehabilitation than two tablets, patients should either place program. Either way, the tablets should be held under the to ngue until they dissolve; swal Treatment With lowing the tablets reduces the bioavailability Buprenorphine of the drug. To ensure consistency in bio availability, patients should follow the same the three phases of maintenance treatment manner of dosing with continued use of the with buprenorphine for opioid addiction medication. Dissolution rates vary, but, on are (1) induction, (2) stabilization, and average, the sublingual tablets should dissolve (3) maintenance. Treatment Approach Induction Phase There are two general approaches to the Buprenorphine induction (usual duration medication-assisted treatment of opioid approximately 1 week), the first phase of Treatment Pro to cols 51 treatment, involves helping a patient begin the Patients Dependent on process of switching from the opioids of abuse Short-Acting Opioids to buprenorphine. The physician ferably be exhibiting early signs of opioid should assess for signs and symp to ms of with withdrawal. Induction pro to cols explanation of the advantages of waiting and differ, depending on the type of opioid to should be urged to wait until they begin to which the patient is addicted. For patients who do not experience present) after 2 hours, a second dose of 4/1 mg excessive opioid agonist symp to ms after the can be administered. The to tal amount of initial dose, induction pro to cols can be buprenorphine administered in the first day followed as described below.