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					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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