2nd QUARTER APRIL/MAY/JUNE 2011 HPS Newsletter HPS Newsletter MANAGEMENT HOSPITAL PHARMACYPharmacy Management Hospital Hospital Pharmacy Management 3rd QUARTER Hunter Pharmacy Services, Inc. 3420 Executive Center Dr. Suite 100 Austin, Texas 78731 antibiotics, largely due to overuse of Antibiotic these medications. Because superbugs are resistant to these J. Michael Hunter, RPh Superbugs CRKP drugs, they can quickly spread in President/CEO & MRSA: Who's hospitals and the community, causing 800-707-8799 at Risk? infections that are hard or even By Lisa Collier Cook Apr 07, 2011 impossible to cure. Doctors are forced Amy Othold, RPh to turn to more expensive and Chief Operating Officer Misuse of antibiotics has led to a sometimes more toxic drugs of last (C) 830-857-0234 global health threat: the rise of resort. The problem is that every time dangerous—or even fatal— antibiotics are used, some bacteria superbugs. Methicillin-resistant survive, giving rise to dangerous new Ted Morgan staphylococcus aureus (MRSA) is now strains like MRSA and CRKP, the CDC Controller reports. 800-707-8799 attacking both patients in hospitals and also in the community and a deadly new multi-drug resistant What are CRKP and MRSA? Carroll Menasco bacterium called carbapenem- Klebsiella is a common type of gram- MBA/HRM, PHR resistant Klebsiella pneumoniae, or negative bacteria that are found in Director Human Resources/ CRKP, is now in the headlines. our intestines. The CRKP strain is Office Manager resistant to almost all antibiotics, (C) 512-636-1468 Unless steps are taken to address this including carbapenems, the so-called crisis, the cures doctors have counted “antibiotics of last resort.” on to battle bacteria will soon be MRSA is a type of bacteria that live on Debbie Woodby the skin and can burrow deep into the useless. CRKP has now been reported HR Assistant body if someone has cuts or wounds, in 36 U.S. states—and health officials suspect that CRKP may also be including those from surgery. Dorothy Montgomery, CPP triggering infections in the other 14 Bookkeeping/Payroll states where reporting isn’t required. Who is at risk? CRKP and MRSA High rates have been found in long- infect patients, usually the elderly— Mike Petry, RPh, MS, VP term care facilities in Los Angeles who are already ill and living in long- Clinical Pharmacist County, where the superbug was term healthcare facilities, such as previously believed to be rare, nursing homes. People who are on (C) 512-771-9574 according to a study presented earlier ventilators, require IVs, or have this month. CRKP is even scarier than undergone prolonged treatment with Victor Mikeska, RPh MRSA because the new superbug is certain antibiotics face the greatest Regional Director resistant to almost all antibiotics, threat of CRKP infection. Healthy (C) 512-657-0103 while a few types of antibiotics still people are at very low risk for CRKP. work on MRSA. Who’s at risk for There are two types of MRSA, a form Eddie Goode, RPh superbugs—and what can you do to that affects hospital patients with Regional Director protect yourself and family members? similar risk factors to CRKP, and Here’s a guide to these dangerous another even more frightening strain (C) 903-720-8250 bacteria. found in communities, attacking people of all ages who have not been Dawn Rana, RPh Understanding different types of in medical facilities, including Regional Director bacteria. athletes, weekend warriors who use (C) 210-737-4961 What is antibiotic resistance? locker rooms, kids in daycare centers, Almost every type of bacteria has soldiers, and people who get tattoos. Susan Goforth, RPh evolved and mutated to become less Nearly 500,000 people a year are Area Director and less responsive to common hospitalized with MRSA. (C) 432-425-7895 Page 2 HPS Newsletter Keeping hospital patients safe. someone you know is in a nursing suctioned out. It took a year, but How likely is it to be fatal? In earlier home or hospital, make sure doctors it all returned. But it did not outbreaks, 35% of CRKP-infected and staff wash their hands in front of reappear in the women‟s thighs. patients died, Journal of the American you. Also wash your own hands Instead, Dr. Eckel said, “it was Medical Association (JAMA) reported frequently, with soap and water or an redistributed upstairs,” mostly in the upper abdomen, but also in 2008. The death rate among those alcohol-based hand sanitizer, avoid around the shoulders and triceps of affected by the current outbreak isn’t sharing personal items, and shower the arms. yet known. About 19,000 deaths a after using gym equipment. The CDC year are linked to MRSA in the U.S. has reports on Klebsiella bacteria and Dr. Felmont Eaves III, a plastic and the rates of the disease has rise MRSA, discussing how to prevent surgeon in Charlotte, N.C., and 10-fold, with most infections found in their spread and has just issued a new president of the American Society the community. report on preventing bloodstream for Aesthetic Plastic Surgery, said infections. the study was “very well done,” and How does it spread? Both MRSA and the results were surprising. He said CRKP are mainly transmitted by he would mention it to his patients person-to-person contact, such as the With Liposuction, the Belly in the context of other information infected hands of a healthcare Finds What the Thighs Lose on liposuction. By Gina Kolata provider. They can enter the lungs The New York Times The finding raises many questions through a ventilator, causing about plastic surgery. Liposuction pneumonia, the bloodstream through has been around since 1974 and is an IV catheter, causing bloodstream heavily advertised. Why did it take infection (sepsis), or the urinary tract so long for anyone to do this study? through a catheter, causing a urinary tract infection. Both can also cause Maybe it‟s because such a study is surgical wounds to become infected. very difficult, said Dr. Samuel Klein, MRSA can also be spread by contact director of the Center for Human with infected items, such as sharing Nutrition at the Washington razors, clothing, and sports University School of Medicine. It equipment. These superbugs are not takes a team of researchers and money. Fat must be measured spread through the air. The woman‟s hips bulged in precisely, with scans. unsightly saddlebags. Then she had What are the symptoms? Since liposuction and, presto, those photo And surgery, said Jonathan Moreno, CRKP presents itself as a variety of after photo on plastic surgery Web an ethicist at the University of sites make liposuction look easy, illnesses, most commonly pneumonia, Pennsylvania who has studied the the results transformative. meningitis, urinary tract infections, field, is not like other areas of Liposuction has become the most wound (or surgical site) infections, medicine. “A lot of it has to do with popular plastic surgery, with more and blood infections, symptoms the culture of surgery, which is than 450,000 operations a year, reflect those illnesses, most often literally hands-on,” he said. each costing a few thousand pneumonia. MRSA typically causes Surgeons, he added, often feel a dollars. deep connection to their patients boils and abscesses that resemble But does the fat come back? And if that makes it difficult for them to infected bug bites, but can also it does, where does it show up? agree to clinical trials that involve present as pneumonia or flu-like randomizing patients. Another symptoms. Until now, no one knew for sure. problem, Dr. Moreno said, is that But a new study, led by Drs. Teri L. different surgeons have different How are superbugs related? The Hernandez and Robert H. Eckel of skills and different techniques. the University of Colorado, has only drug that still works against the Surgery is not like taking a drug, answered those questions. And CRKP is colistin, a toxic antibiotic that where one pill is just like every what was found is not good news. can damage the kidneys. Several other. drugs, such as vancomycin, may still In the study, the researchers work against MRSA. So instead of doing rigorous randomly assigned non-obese studies, surgeons tend to innovate, women to have liposuction on their inventing their own procedures and What’s the best protection against protuberant thighs and lower publishing anecdotes about superbugs? Healthcare providers are abdomen or to refrain from having patients, a practice that can be prescribing the procedure, serving as controls. misleading. fewer antibiotics, As compensation, the women who to help prevent were control subjects were told that But in this case, the outcome did CRKP, MRSA and when the study was over, after they not depend on the surgeon. It learned the results, they could get other superbugs depended on the biology of fat; and liposuction if they still wanted it. from developing obesity researchers say they are For them, the price would also be resistance to not surprised that the women‟s fat reduced from the going rate. even more came back. The body, they say antibiotics. The “defends” its fat. If you lose weight, The result, published in the latest best way to stop bacteria from even by dieting, it comes back. issue of Obesity, was that fat And, the study showed, if you suck spreading is simple hygiene. If came back after it was Page 3 HPS Newsletter out the fat with liposuction, even if 20 Worst Drinks in 18. Worst Energy Drink it‟s only a pound, as it was for Rockstar Energy subjects in the study, it still comes America Drink By: Mens Health Magazine back. www.menshealth.com (1 can, 16 fl oz) 280 calories, 0 g fat, “It‟s another chapter in the „You Over the past 50 years or so, we 62 g sugars can‟t fool Mother Nature‟ story,‟ ” Americans have developed a severe Sugar Equivalent: 6 said Dr. Rudolph Leibel, an obesity drinking problem. Krispy Kreme Original Glazed researcher at Columbia University. Doughnuts We stopped making our own iced teas Some researchers have their own and lemonades (recipe: water, lemon, None of the energy provided by these anecdotes. Dr. George Bray, a sugar) and started buying them in bottles full-sugar drinks could ever justify the professor of medicine at Louisiana or mixes, with ingredients like "high- caloric load, but Rockstar’s take is State University, once saw a young fructose corn syrup" and "ascorbic acid" especially frightening. One can provides woman who was so distraught by on the labels. We stopped thinking of a nearly as much sugar as half a box of her protruding abdomen that she soda as a treat - akin to an ice cream or a Nilla Wafers. In fact, it has 60 more had an operation to slice off some candy bar - and started seeing it as the calories than the same amount of Red of her abdominal fat. “Her lower equivalent of a glass of water, drinking Bull and 80 more than a can of Monster. abdomen was considerably two, three, four, or more a day. Then we thinner,” Dr. Bray said. “But the stopped drinking water out of the tap 17. Worst Bottled Coffee areas above it picked up the extra Starbucks Vanilla and started demanding that it be fat.” Frappuccino artificially flavored and put into bottles (1 bottle, 13.7 fl oz) with the words "vitamin" or "energy" Then there are the studies with 290 calories, 4.5 g fat (2.5 g stamped on the labels. And, in just the saturated), 45 g sugars laboratory rodents that had fat last decade or so, many of us stopped Sugar Equivalent: 32 Nilla Wafers surgically removed. The fat always brewing our own coffee and started came back. And, like the women in buying things with vaguely European With an unreasonable number of calorie the new study, the rodents got their names, like "mocha latte." And the result landmines peppered across Starbucks’ fat back in places other than the of all this beverage evolution is that, in-store menu, you’d think the company place where it was removed, Dr. today, walking into a convenience store would want to use its grocery line to Klein reported. They grow new fat or a beverage distributorship has become restore faith in its ability to provide cells to replace the ones that were dangerous to our health. caffeine without testing the limits of lost. your belt buckle. Guess not. This drink 20. Worst Water has been on our radar for years, and we The same thing happened to the Snapple Agave Melon still haven’t managed to find a bottled women who had liposuction. It Antioxidant Water coffee with more sugar. turns out, Dr. Leibel said, that the (1 bottle, 20 fl oz) body controls the number of its fat 150 calories, 0 g fat, 33 16. Worst Soda cells as carefully as it controls the g sugars Sunkist amount of its fat. Fat cells die and Sugar Equivalent: 2 Good Humor (1 bottle, 20 fl oz) new ones are born throughout life. Chocolate Éclair Bars 320 calories, 0 g fat, 84 g Scientists have found that fat cells sugars live for only about seven years and While “Worst Water” may sound like an Sugar Equivalent: 6 that every time a fat cell dies, oxymoron, the devious minds in the Breyers Oreo Ice Cream Sandwiches another is formed to take its place. bottled beverage industry have even found a way to besmirch the sterling Wait . . . but aren’t all sodas equally But why wouldn‟t the women grow reputation of the world’s most essential terrible? It’s true they all earn 100% of new fat cells in their thighs? The compound. Sure, you may get a few calories from sugar, but that doesn’t answer, Dr. Klein said, may be that extra vitamins, but ultimately, you’re mean there aren’t still varying levels of liposuction violently destroys the paying a premium price for gussied-up atrocity. Despite the perception of fishnet structure under the skin sugar water. healthfulness, fruity sodas tend to carry where fat cells live. more sugar than their cola counterparts, 19. Worst Bottled Tea and none make that more apparent than Nonetheless, the women in the SoBe Green Tea the tooth-achingly sweet Sunkist. But study who had liposuction were (1 bottle, 20 fl oz) what seals the orange soda’s fate on our happy, Dr. Eckel said. They had 240 calories, 0 g fat, 61 g list of worsts is its reliance on the hated their hips and thighs and just sugars Sugar Equivalent: 4 slices Sara Lee artificial colors yellow 6 and red 40—two wanted that fat gone. chemicals that may be linked to Cherry Pie behavioral and concentration problems As for the women in the control in children. group, when the study ended and Leave it to SoBe to take an otherwise they knew the results, more than healthy bottle of tea and inject it with enough sugar to turn it into dessert. The 15. Worst Beer half still chose to have liposuction. Sierra Nevada Bigfoot Pepsi-owned company’s flagship line, (1 bottle, 12 fl oz) composed of 11 flavors with names like 330 calories, 0 g fat, “Nirvana” and “Cranberry Grapefruit 32.1 g, carbohydrates, Elixir,” is marketed to give consumers 9.6% alcohol the impression that it can cleanse the Carbohydrate Equivalent: 12-pack of body, mind, and spirit. Michelob Ultra Page 4 HPS Newsletter Most beers carry fewer than 175 calories, are guilty of the same crime), but that saturated fat. Makes us wonder what’s but even your average extra-heady brew this behemoth serving size costs just $.99, going on in the hot chocolate. rarely eclipses 250. That makes Sierra’s making its contents some of the cheapest Bigfoot the undisputed beast of the beer calories we’ve ever stumbled across. 8. Worst Frozen Mocha jungle. Granted, the alcohol itself Così Double Oh! Arctic provides most of the calories, but it’s the 11. Worst Espresso Drink Mocha (gigante, 23 fl oz) extra heft of carbohydrates that helps Starbucks Peppermint 662 calories, 26 g fat (15 g stuff nearly 2,000 calories into each six- White Chocolate Mocha saturated), 88 g sugars pack. For comparison, Budweiser has with Whipped Cream Sugar Equivalent: 19 Oreo Cookies 10.6 grams of carbs, Blue Moon has 13, (venti, 20 fl oz) and Guinness Draught has 10. 660 calories, 22 g fat (15 g saturated), 95 The good news here is that this drink g sugars used to be twice as bad - and used to 14. Worst Kids' Drink Sugar Equivalent: 8½ scoops Edy’s contain as much sugar as in 41 Oreo Tropicana Tropical Slow Churned Rich and Creamy Coffee Cookies. The bad news is that even Fruit Fury Twister (1 Ice Cream though it's halved the calories, it's still a bottle, 20 fl oz) piece of work. A frozen mocha will never 340 calories, 0 g fat, 60 g sugars Hopefully this will dispel any lingering be a stellar option, but we’ve still never Sugar Equivalent: Two 7-ounce fragments of the “health halo” that still come across anything that competes with canisters Reddi-Wip exists in coffee shops—that misguided this cookie-coffee-milkshake hybrid from belief that espresso-based beverages Così. Essentially it’s a mocha Blizzard Don’t let Tropicana’s reputation for can’t do much damage. In this 20-ounce made with Oreo cookies and topped unadulterated OJ lead you to believe that cup, Starbucks manages to pack in more with whipped cream and an oversize the company is capable of doing no calories and saturated fat than two slices Oreo. The result is a beverage with more wrong. As a Pepsi subsidiary, it’s of deep-dish sausage and pepperoni calories than two Big Macs and more inevitable that they’ll occasionally delve pizza from Domino’s. That makes it the sugar than any other drink in America. into soda-like territory. The Twister line equivalent of dinner and dessert is just that: a drink with 10% juice and disguised as a cup of coffee. 7. Worst Frozen Coffee 90% sugar laced with a glut of artificial Drink flavors and coloring. You could actually 10. Worst Lemonade Dairy Queen Caramel save 200 calories by choosing a can of Auntie Anne’s Wild MooLatte Pepsi instead. Cherry Lemonade Mixer (24 fl oz) (32 fl oz) 870 calories, 24 g fat (19 g saturated, 1 g 13. Worst Functional 470 calories, 0 g fat, 110 g trans), 112 g sugars Beverage sugars Sugar Equivalent: 12 Dunkin’ Donuts Arizona Rx Energy Sugar Equivalent: 11 bowls of Bavarian Kreme Doughnuts (1 can, 23 fl oz) Cookie Crisp cereal 345 calories, 0 g fat, 83 g Coffee-dessert hybrids are among the sugars There is no such thing as healthy worst breed of beverages. This one Sugar Equivalent: 6 Cinnamon Roll lemonade, but Auntie’s line of delivers 1 gram of fat and 4.6 grams of Pop-Tarts Lemonade Mixers takes the concept of sugar in every ounce, making even hyper-sweetened juice and stretches it to Starbucks’ over-the-top line of Obviously Arizona took great pains in dangerous new levels. See, sugar digests Frappuccinos look like decent options. making sure this can came out looking faster than good-for-you nutrients like Maybe that’s why DQ decided to give it like something you’d find in a pharmacy. protein and fiber, which means it’s in a name that alludes to the animal it But if your pharmacist ever tries to sell your blood almost immediately after you promises to turn you into. If you can you this much sugar, he should have his swallow it. Drinking the 3 or 4 days’ bring yourself to skip DQ and head to a license revoked. And if it’s energy you’re worth of added sugar found here jacks coffee shop instead, order a large iced after, this isn’t your best vehicle. Caffeine your blood sugar and results in strain to latte with a couple shots of flavored is the only compound in the bottle that’s your kidneys, the creation of new fat syrup and save some 600 calories been proven to provide energy, and the molecules, and the desire to eat more. amount found within is about what 6. Worst Margarita you'd get from a weak cup of coffee. 9. Worst Hot Chocolate Traditional Red Starbucks White Hot Lobster Lobsterita 12. Worst Juice Chocolate with Whipped (24 fl oz) Imposter Cream (venti, 20 fl oz) 890 calories, 0 g fat, 183 Arizona Kiwi 520 calories, 16 g fat (11g g carbohydrates Strawberry saturated) 75 g sugars Carbohydrate Equivalent: 7 Almond (1 can, 23 fl oz) Sugar Equivalent: 9 Strawberry Joy candy bars 345 calories, 0 g fat, 81 g sugars Rice Krispie Treats Sugar Equivalent: 7 bowls of Of all the egregious beverages we’ve Froot Loops See that stack of Rice Krispie Treats? It’s analyzed, the Lobsterita surprised us the just three treats shy of two full boxes. most. The nation’s biggest fish purveyor The twisted minds at the Arizona factory Unless you were a contestant on Fear is one of the few big players in the outdid themselves with this nefarious Factor—and there was a sizeable restaurant biz to provide its customers concoction, a can the size of a bazooka monetary prize on the line—you’d never with a wide selection of truly healthy loaded with enough of the sweet stuff to even consider noshing down that much food options. We would hope they’d do blast your belly with 42 sugar cubes. The sugar at once. But here’s what’s the same with the beverages, but most disturbing part isn’t that it masks interesting: While that stack is the sugar obviously not. Drink one of these every itself as some sort of healthy juice counterpart to this atrocity from Friday night and you’ll put on more than product (after all, hundreds of products Starbucks, it still has 40 percent less a pound of flab each month. Downgrade Page 5 HPS Newsletter to a regular margarita on the rocks and it’s most likely America’s most popular OLD ADVICE: Many women with pocket the remaining 640 calories. milk shake. high cholesterol should take statins to help prevent heart disease. 5. Worst Float 2. Worst Smoothie Baskin-Robbins Ice Smoothie King Peanut Cream Soda (vanilla Power Plus Grape (large, NEW ADVICE: Recent research ice cream and cola) 40 fl oz) suggests that cholesterol-lowering (large, 28.6 fl oz) 1,498 calories, 44 g fat (8g statins are most effective for women 960 calories, 40 g fat (25 g saturated, 1.5 saturated) 214 g sugars who already have heart disease or g trans), 136 g sugars Sugar Equivalent: 20 Reese's Peanut are at increased risk for getting it. Sugar Equivalent: 9.7 Fudgsicle Butter Cups The higher your risk, the more likely fudge bars you are to benefit from statins. If Smoothie King wants someone to Done right, an ice cream float can be a blame for landing this high on our worst decent route to indulgence. Go to A&W beverages roundup (and truth be told, its OLD ADVICE: Thirty minutes of and you’ll land a medium for fewer than entire menu is riddled with contenders), daily exercise is enough to keep 400 calories. Order it with diet soda and the chain should point the smoothie your heart healthy. you’ve dropped below 200 calories. So straw at whichever executive came up why can’t Baskin-Robbins make even a with the cup-sizing structure. Sending NEW ADVICE: Women need a full small float with fewer than 470 calories? someone out the door with a 40-ounce hour of moderate activity each day Because apparently the chain approaches cup should be a criminal offense. Who to reduce their risk of heart disease. the art of beverage-crafting as a really needs a third of a gallon of challenge to squeeze in as much fat and sweetened peanut butter blended with This doesn’t have to mean logging sugar as possible. grape juice, milk, and bananas? Sugar- time at the gym—it could include and-fat-loaded smoothies like this doing yard work, washing the car, 4. Worst Frozen Fruit should be served from 12-ounce cups, or taking a brisk walk. Drink not mini kegs. Quiz: Are You Heart Health Savvy? Krispy Kreme Lemon Sherbet Chiller (20 fl oz) 1. Worst Beverage in OLD ADVICE: All adults should 980 calories, 40 g fat (36 America g saturated) 115 g sugars take a daily aspirin to prevent heart Cold Stone PB&C Sugar Equivalent: 16 medium-size (Gotta Have It size, attack. chocolate éclairs 24 fl oz) 2,010 calories, 131 g fat (68 g saturated), NEW ADVICE: Take daily aspirin Imagine taking a regular can of soda, 153 g sugars only if you’re over 65, have had a pouring in 18 extra teaspoons of sugar, Sugar Equivalent: 30 Chewy Chips heart attack, or are at high risk for and then swirling in half a cup of heavy Ahoy Cookies heart disease. Otherwise, the risks cream. Nutritionally speaking, that’s from taking too much aspirin (like exactly what this is, which is how it In terms of saturated fat, drinking this manages to marry nearly 2 days’ worth Cold Stone catastrophe is like slurping gastrointestinal bleeding) likely of saturated fat with enough sugar to up 68 strips of bacon. Health experts outweigh the benefits. leave you with a serious sucrose recommend capping your saturated fat hangover. Do your heart a favor and intake at about 20 grams per day, yet this OLD ADVICE: You’re probably not avoid any of Krispy Kreme’s “Kremey” beverage packs more than three times at significant risk for heart disease beverages. The basic Chillers aren’t the that into a cup the size of a Chipotle unless you smoke, are obese, or safest of sippables either, but they’ll save burrito. But here’s what’s worse: No have a history of diabetes, high you up to 880 calories. regular shake at Cold Stone, no matter cholesterol, or hypertension. what the size, has fewer than 1,000 3. Worst Drive-Thru calories. If you must drink your ice Shake cream, make it one of the creamery’s NEW ADVICE: Be aware of other McDonald’s Triple “Sinless” options. Otherwise you’d health problems that increase the Thick Chocolate better plan on buying some bigger pants risk of heart disease. These include - Shake (large, 32 fl oz) on the way home. preeclampsia (high blood pressure 1,160 calories, 27 g fat (16 g saturated, 2 during pregnancy), lupus, and g trans), 168 g sugars MEDICAL rheumatoid arthritis. — Sugar Equivalent: 13 McDonald’s Baked Hot Apple Pies UPDATE: New Wisdom Get Smart About Vitamin D There are very few milk shakes in For Strong America worthy of your hard-earned Hearts bone For calories, but few will punish you as By: Amanda Schupak thoroughly as this Mickey D’s drive-thru health, disaster. Not only does it have more than The American Heart Association vitamin D half your day’s caloric and saturated fat recently updated its guidelines to and calcium allotment and more sugar than you’d find in Willy Wonka’s candy lab, but help women prevent heart disease go hand in Ronald even finds a way to sneak in a and stroke. We asked lead author Dr. Lori Mosca to talk us through hand; the vitamin must be full day of cholesterol-spiking trans fat. The scariest part about this drink is that some of the changes. present for calcium to be absorbed from the digestive Page 6 HPS Newsletter tract. But more D isn’t time is greater than eight hours. Light Therapy necessarily better. In fact, Eastbound travel is associated with Sunlight has a major influence a longer duration of jet lag than on the internal circadian clock. research has determined that westbound travel. Traveling across several time consuming very high levels of zones necessitates resetting and Vitamin D through Role of the Internal Circadian adjusting to a new daylight supplement can lead to an Clock schedule. Natural light exposure is increased risk of fractures. A To appreciate the factors associated the ideal mechanism for with jet lag, it is helpful to counteracting jet lag. For those committee of specialists understand the basic properties of who travel frequently or are recently concluded that most the body's internal clock. The unable to have exposure to natural adults get sufficient D from central circadian clock is located in sunlight, exposure to bright artificial sunlight and their regular the hypothalamus, where light light may be of benefit. diets. signals from the retina are received. It is responsible for Melatonin adapting the circadian rhythm In the human body, sleep is initiated according to the light–dark cycles during a rise in the concentration of of the environment and for melatonin and during the declining generating neuronal and hormonal phase of body temperature. activities that regulate various Synthesized from serotonin in the Small body functions in a 24-hour cycle. pineal gland, melatonin helps Doses….. Zeitgebers (time-givers, or shift human circadian rhythms. An increase in melatonin alerts the By Mike Petry, MS, RPh synchronizers) are rhythmic cues body that "biological night" is Clinical Pharmacist in the environment that starting, whereas a decline in synchronize the internal body melatonin alerts the human body Jet Lag - Current and Potential clock to the earth's 24-hour light– that biological night is ending. Therapies dark cycle. Light is the strongest Administering exogenous melatonin zeitgeber; other non-photic in the afternoon to evening hours of Jet lag, also known as circadian zeitgebers include temperature, a 24-hour day promotes an advance desynchrony, is a sleep disorder social interaction, in circadian rhythm, which may where there is a mismatch with the pharmacological manipulation, help travelers overcome symptoms. body's natural circadian rhythm exercise, and meal timing. It is and the external environment, easiest to initiate sleep when the Ramelteon which is usually due to rapid body temperature is at its lowest, Ramelteon (Rozerem®), a travel across multiple time zones. coupled with an increase in melatonin receptor agonist, has This common problem affects all melatonin secretion. When the been approved by the FDA for age groups, but may have more body clock is inappropriately insomnia. The dose is usually 8 mg, pronounced effects on the elderly phased, sleep is difficult to initiate taken one half-hour before whose recovery rate may be more and maintain. bedtime. The selectivity of prolonged than that in young adults. ramelteon for melatonin Prevention and Management of receptors, normally acted upon A multitude of factors, such as Jet Lag by endogenous melatonin, induces the number of time zones The goal of prevention and sleep and can help maintain the crossed, the time of travel, and the treatment of jet lag is to achieve circadian rhythm underlying the direction traveled play a role in circadian realignment in the most normal sleep–wake cycle. Adverse the severity of symptoms rapid and efficient way possible effects of ramelteon are similar to experienced by travelers. Travelers while minimizing the symptoms. those of melatonin. It does not usually experience symptoms after The aggressiveness of treatment appear that ramelteon leads to crossing at least two time zones. often depends on the length of stay dependence or withdrawal effects Symptoms may include disturbed in the new time zone. For example, after discontinuation. sleep, daytime fatigue, decreased business travelers, pilots, and ability to perform mental and flight attendants may experience Zolpidem physical tasks, reduced alertness, frequent but brief shifts in time Zolpidem (Ambien®), a non- and headaches. Sleep zones, and it may be practical for benzodiazepine hypnotic, binds the disturbances typically last for a them to just remain on their normal benzodiazepine receptor subunit of few days, but they can persist for as sleep/wake schedule. the GABA-A receptor complex. It has long as a week if the change in a strong hypnotic effect with weak anticonvulsant and muscle-relaxant Page 7 HPS Newsletter properties. Although the FDA has Conclusion "It’s no longer just about UV dam- not approved this drug for jet lag, the Jet lag is a sleep disorder age," says Fredric Brandt, MD, a use of zolpidem as a way to cope with common to travelers of all age dermatologist in New York City and symptoms might be suitable for groups. The disorder is caused by Miami. "The sun also generates free those who travel often for work and rapid travel across multiple time radicals that break down your who are required to be active and zones in which the circadian collagen and elastin fibers." Anti- alert as soon as they arrive in the new system is not able to adjust to the oxidants in ingredients like soy, green tea, and vitamin C prevent time zone. It is effective because of rapid shift. The speed of free radicals from attacking, and its rapid absorption, short half-life, resynchronization of circadian they boost your protection level, too. and inactive metabolites. Adverse rhythm to the new time zone Use a suncreen that contains the effects include dizziness, depends on multiple factors. Jet- powerful antioxidant idebenone or somnolence, memory loss, lagged travelers may experience make sure your daily moisturizer headache, and nausea. When low disturbed sleep, daytime fatigue, has antioxidants in it so you’re doses recommended for initiating poor performance in mental and covered from the start, then apply sleep are used, carryover effects physical tasks, decreased alertness, sunscreen as usual. should be minimal the next day. and headache. Several prescription and over-the-counter (OTC) If you’re going to the beach, go Caffeine products are used in the higher than SPF 15, Dr. Brandt says. Caffeine is a common remedy for management of jet lag. Most people don’t apply enough, so treating sleepiness induced by jet Pharmacists can aid patients in they may lag. Studies have shown that it can selecting an appropriate, effective end up getting a protection level of 7 be an effective way to reduce or treatment. out of their 15. But if you’re overcome symptoms of jet lag. One slathering on 70 you’ll probably get study found that caffeine led to an Sign for pharmacy nursing in- at least a 30, so you’re good. objective decrease in daytime service: Old rule: Throw on a T-shirt or sleepiness compared with melatonin cover-up when you’re in direct and placebo, as assessed by multiple ___________________________ sunlight. sleep latency tests. Signature New rule: If you’re not into sun Diphenhydramine ___________________________ protective clothing, wear dark colors (Benadryl®) is the most common Date and tightly woven fabrics at peak nonprescription antihistamine hours. You can’t get away with any prescribed for insomnia. Side The New Rules of ol’ thing (donning effects can include daytime Sun Safety a breezy sarong is sleepiness, cognitive impairment, like wearing By Llana Blitzer dizziness, blurred vision, and dry www.health.com nothing at all). mouth. Self-medication is a common April 25, 2011 Fabrics have UPF problem that can result in adverse ratings that You’ve been following the rules measure their level of UV outcomes, especially in older adults. when it comes to sunscreen for how The use of diphenhydramine should protection; a 30 is necessary to be long now? At this point, you’re a awarded the Skin Cancer be avoided in elderly persons who are diligent daily sunscreen wearer, and often sensitive to its anticholinergic Foundation’s Seal of you know to reapply every few Recommendation. (FYI: A plain properties. hours when you’re at the beach or white tee comes in under 10.) If pool. But, hey, it’s 2011—some of you’re up for a quick extra step, Armodafinil (Nuvigil®), a central the old thinking no longer applies. check out SunGuard Sun nervous system (CNS) stimulant, is So update your sun-safety habits, Protection, a clear dye you can add used to improve wakefulness in and keep your skin healthy long- to your laundry for an immediate adults who experience excessive term with these thoroughly modern UPF 30 that will last through 20 sleepiness because of obstructive strategies. washings. sleep apnea, shift-work disorder, and narcolepsy. Most adverse Old rule: Apply a broad-spectrum Old rule: Use a teaspoon of effects are mild to moderate and UVA/UVB sunscreen with SPF 15 a sunscreen for your face, a shot- include headache, nausea, diarrhea, half-hour before leaving the house. glass-worth for your body. circadian rhythm sleep disorder, and New rule: Sunscreen alone is not New rule: Layer on your protection palpitations. The FDA has refused enough: Wear an SPF 15 (at least) to make sure you are covered. to approve the use of armodafinil for plus an antioxidant-enriched the treatment of jet lag, and the moisturizer. manufacturer has withdrawn its Because nobody actually measures request for FDA approval. out their dose, here’s how to stay Page 8 HPS Newsletter safe. First, err on the side of over by UV radiation, the Skin Cancer Paranasal sinuses, because of their applying. Pay attention to Foundation reports. relatively narrow connecting passageways, are uniquely susceptible commonly missed spots like your to barotraumas, generally on descent. neck, chest, and the backs of your But there’s one tan that is safe: the With small changes in pressure (depth), hands, particularly when you’re kind you slather on. According to a symptoms are usually mild and short driving. "Most people don’t realize study in Archives of Dermatology, lived, but can be exacerbated by that the neck and the V of the chest when women are taught to use self- continued diving. Larger pressure are directly exposed to sunlight due tanners, they spend less time in the changes, especially with forceful attempts at equilibration (e.g., valsalva to the angle of the windshield, sun because they aren’t longing to maneuver), can be more injurious. which offers no protection from bake for the tan. Try one that gives a Additional risk factors for ear and sinus UVA rays," says Alysa Herman, gradual tint and help fade existing barotrauma include— MD, a Miami dermatologist sun spots. Now that’s a healthy specializing in skin cancer glow. earplugs treatment. "The backs of hands also medications get a lot of damage from holding the ear and/or sinus surgery steering wheel." A nonstick spray- on sunscreen is an easy way to cover SCUBA DIVING nasal deformity disease all those spots without getting your A diver who may have sustained ear or hands tacky. To max out your face Daniel A. Nord sinus barotrauma should discontinue coverage, apply a sunscreen lotion CDC 2011 diving and seek medical attention. and follow up by dusting on a powder-based mineral blocker. It Scuba diving can present a variety of Pulmonary has the added benefit of de-slicking unique medical challenges for the It is critical for a scuba diver to exhale (or post-sunscreen shine. A skin-win! traveling diver. Because diving injuries breathe normally) while ascending are generally rare, few health-care slowly. Over inflation of the lungs, which providers are trained in their diagnosis usually happens when a novice diver Old rule: A little sun is healthy—20 and treatment. Thus, the recreational panics, can result as a scuba diver minutes three times a week allows diver must be able to recognize the signs ascends toward the surface without your body to produce vitamin D. of injury and ensure the availability of exhaling. During ascent, compressed dive medicine help when needed. gas trapped in the lung increases in volume until the expansion exceeds the New rule: It’s not smart to go out- Fitness to Dive elastic limit of lung tissue, causing of-doors unprotected. damage and allowing gas bubbles to Planning for dive-related travel should escape into one or more of three take into account any changes in health Here’s the deal: Your body does possible locations, as follows: status, recent injuries, or surgery. In need vitamin D to keep bones general, respiratory disorders, as well as healthy and support your immune any disorders affecting higher function Gas entering the pleural space can cause lung collapse or system, but supplements are the and consciousness (e.g., diabetes pneumothorax. safest way to get your dose of mellitus or seizures), respiratory function [vitamin] D—without the scary side (e.g., asthma), psychological problems Gas entering the mediastinum (e.g., anxiety), and pregnancy raise (space around the heart, effects of sun exposure. "Even a little special concerns about diving fitness. trachea and esophagus) bit of sun causes cellular damage causes mediastinal that can lead to aging and cancer," Diving Disorders emphysema and frequently says Francesca Fusco, MD, a Barotrauma tracks under the skin dermatologist in New York City. (subcutaneous emphysema) Ear and Sinus Have your doctor check your or into the tissue around the Ear barotrauma is the most common larynx, sometimes precipitating [vitamin] D level; if it’s low, discuss injury in divers. On descent, failure to a change in the voice taking a daily supplement equalize pressure changes within the characteristics. containing 400 to 1,000 IU. middle ear space creates a pressure gradient across the eardrum, which can Gas rupturing the alveolar walls can dissect into the Old rule: Never, ever go tanning. cause bleeding or fluid accumulation in the middle ear, as well as stretching or pulmonary capillaries and pass rupture of the eardrum and the via the pulmonary veins to the New rule: Still, never, ever go membranes covering the windows of the left side of the heart, where it tanning—indoors or outdoors. inner ear. Symptoms can include— is distributed according to relative blood flow, resulting in Using a tanning pain arterial gas embolism (AGE). bed increases your tinnitus (ringing in the ears) While mediastinal or subcutaneous risk for melanoma emphysema usually resolves vertigo (dizziness or sensation spontaneously, pneumothorax generally by up to 75%, of spinning) requires specific treatment to remove the according to the International sensation of fullness air and reinflate the lung. AGE is a Agency for Research on Cancer. medical emergency requiring appropriate And 90% of the signs of aging effusion (fluid accumulation in intervention, which includes the ear) recompression treatment with hyperbaric (wrinkles, brown spots) are caused decreased hearing oxygen. Page 9 HPS Newsletter Lung overinflation injuries from scuba supersaturate tissues, where it separates certification and should be done with a diving can range from dramatic and life from solution to form bubbles, interfering companion. threatening to mild symptoms of chest with blood flow and tissue oxygenation pain and dyspnea. Although pulmonary and causing signs and symptoms of Treatment of Diving Disorders barotrauma is relatively uncommon in decompression sickness. These Definitive treatment of DCI begins with divers, prompt medical evaluation is symptoms include— early recognition of symptoms, followed necessary, and evidence for this by recompression with hyperbaric condition should always be considered in joint aches or pain oxygen. A high concentration (100%) of the presence of respiratory or neurologic symptoms following a dive. numbness and/or tingling supplemental oxygen is considered mottling or marbling of skin effective first aid in relieving the signs Decompression Illness and symptoms of decompression illness coughing spasms or shortness and should be administered as soon as Decompression illness (DCI) is an all- of breath possible. Divers are often dehydrated, inclusive term that describes the dysbaric injuries, AGE, and decompression itching either because of incidental causes, immersion, or DCI itself, which can sickness (DCS). Because the two unusual fatigue cause a capillary leak. Administration of diseases are considered to result from dizziness isotonic glucose-free intravenous fluid is separate causes, they are described here separately. However, from a clinical weakness recommended in most cases. Oral rehydration fluids may also be helpful, and practical standpoint, distinguishing personality changes provided they can be safely administered between them in the field may be impossible—and unnecessary, since the loss of bowel or bladder (e.g., if the diver is conscious). The function definitive treatment of DCI is initial treatment is the same for both. DCI recompression and oxygen can occur even in divers who have staggering, loss of administration in a hyperbaric chamber. carefully followed the standard coordination, and/or tremors decompression tables and the principles of safe diving. paralysis The Divers Alert Network (DAN) maintains a 24-hour emergency collapse or unconsciousness consultation and evacuation assistance Arterial Gas Embolism (AGE) Serious permanent injury may result from at 919-684-8111 or 919-684-4326 Gas entering the arterial blood through either AGE or DCS. (collect calls are accepted). DAN will ruptured pulmonary vessels can provide assistance with management of distribute bubbles into the body tissues, Flying after Diving the injured diver, help in deciding if including the heart and brain, where they recompression is needed, the location of The risk of developing decompression disrupt circulation. AGE may cause the closest recompression facility, and sickness is increased when divers are minimal neurologic symptoms or assistance in arranging patient transport. exposed to increased altitude too soon dramatic symptoms that require DAN can also be contacted for routine following a dive. The cabin pressure of immediate attention. These signs and nonemergency consultation by telephone commercial aircraft may be the symptoms include— at 919-684-2948, ext. 222, or by equivalent of 8,000 ft (2,438 m). Thus, divers should avoid flying or an altitude accessing the website numbness exposure >2,000 ft (610 m) for— www.diversalertnetwork.org . weakness Travelers who plan to scuba dive may tingling a minimum of 12 hours after want to ascertain whether there are surfacing from a single no- dizziness decompression dive, or recompression facilities at their destination prior to embarking on their visual blurring after repetitive dives and/or trip. chest pain multiple days of diving, wait a References personality change minimum of 18 hours before ascending to altitude, to 1. Brubakk AO, Neuman TS, paralysis or seizures reduce the risk of editors. Bennett and Elliot’s loss of consciousness decompression sickness. physiology and medicine of death These recommended preflight surface diving. 5th ed. London: intervals do not guarantee avoidance of Saunders Ltd.; 2003. In general, any scuba diver who surfaces DCS. Longer surface intervals will further 2. Moon RE. Treatment of unconscious or loses consciousness reduce DCS risk. decompression illness. In: within 10 minutes after surfacing should be assumed to have AGE. Intervention Prevention of Diving Disorders Bove AA, Davis J, editors. with basic life support is indicated, Diving medicine. 4th ed. including the administration of 100% Recreational divers should dive London: Saunders; 2004. p. oxygen, followed by rapid evacuation to conservatively and well within the limits 195–223. a hyperbaric oxygen treatment facility. of their dive tables or computers. Risk 3. Sheffield PJ, Vann RD. Flying factors for DCI are primarily dive depth after recreational diving: Decompression Sickness and bottom time; however, factors such workshop proceedings. Divers Breathing air under pressure causes as rapid ascent, repetitive dives, Alert Network. 2004 [cited excess inert gas (usually nitrogen) to strenuous exercise, dives >60 feet, 2008 Nov 25]. Available dissolve in body tissues. The amount altitude exposure soon after a dive, and from:http://www.diversalertnet dissolved is proportional to and physiological variability also increase work.org/research/projects/fad/ increases with depth and time. As the risk. Divers should be cautioned to stay workshop/ . diver ascends to the surface, the excess well hydrated and rested, dive within the dissolved gas must be cleared through limits of their training, and follow 4. Thalmann ED. DAN dive and respiration via the bloodstream. established guidelines for dives unique to travel medical guide. rev. ed. Depending on the amount dissolved and their travel destination. Diving is a skill 2003. Durham, NC: Divers the rate of ascent, some gas can that requires appropriate training and Alert Network.
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