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by Mike Cadogan, MB ChB

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Crossing multiple time zones can produce a constellation of symptoms known as jet lag.

Jet lag is most noticeable in the first 24-48 hours following travel and can last for up to 5 days before individuals return to normal functioning. Symptoms are closely affected by both the length and direction of travel. Symptoms include: reduced alertness, night-time insomnia, loss of appetite, depressed mood, poor psychomotor coordination and reduced cognitive skills. Work capacity and peak power are also reduced.

Factors affecting poor recovery from travel include

• A lack of sleep or very restless sleep during flight
• Dehydration from dry environment of the aeroplane cabin (contribute to tachycardia and headaches)
• Number of time zones crossed
• Direction of travel (westward travel is easier to tolerate than eastward)
• Fitness levels (fitter people adapt better after travel)
• Personality (outgoing types appear to adjust quicker)

One of the major challenges of travelling with elite athletes is to minimise the negative symptoms associated with international travel in as natural a way as possible. To best refine a travel management plan it is first prudent to understand the pathophysiology of the sleep/wake cycle.

Daily circadian variation exists in elite athletes with peak performance occurring in the afternoon and early evening with improved flexibility, reaction time, strength and mood at this time of day. International travel disturbs these circadian rhythms and can have a negative impact on performance.

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Melatonin

Synthesis of melatonin by the pineal gland is inhibited by light and stimulated by darkness.

Melatonin has been dubbed the “hormone of darkness.” Secretion of melatonin commences each evening as the Dim-Light Melatonin Onset (DLMO), peaks in the middle of the night, and gradually falls during the second half of the night, with normal variations in timing according to an individual’s chronotype.

Increases in the level of melatonin causes the body to feel less alert and has an important role in inducing sleep and producing the symptoms of jet lag.

Dysregulation of melatonin secretion and circadian rhythm disturbances are thought to be the common links which underlie jet lag and affective mood disorders. As a result of its regulatory effects on the circadian system, it follows that melatonin may be used effectively to treat the range of symptoms that accompany transmeridian air travel.

Melatonin acts on MT(1) and MT(2) melatonin receptors located in the hypothalamic suprachiasmatic nuclei, the site of the body’s master circadian clock. Melatonin can reset disturbed circadian rhythms and promote sleep in jet lag and other circadian rhythm sleep disorders, including delayed sleep phase syndrome and shift-work disorder. Post-flight melatonin administration works efficiently in transmeridian flights across less than 7-8 times zones.

Pharmacological implications

Despite pathophysiological evidence, there is still a persisting culture of players requesting stronger sedative agents to assist in artificially creating a new time-zone sleep/wake cycle. Agents such as bezodiazepine (diazepam) and non-benzodiazepine hypnotics such as Zolpidem are still frequently prescribed to travelling elite athletes to reduce the negative symptoms of jet lag.

I am currently implementing a more evidence based approach to the management of circadian cycle disruption by administering melatonin or the newer melatonin receptor agonists. On this South African tour we are trialling the use of direct sunlight exposure for 30 minutes each morning (in addition to daily excersise regimes) and the administration of 2-4 mg doses of melatonin at normal bedtime in the setting of darkness (22:00 local time). So far the administration of melatonin has had a fantastic effect in organing an effective sleep/wake cycle for the players and has drastically reduced the administration of previously abused agents.

Ramelteon and agomelatine are melatonin receptor agonists which, compared to melatonin itself, have a longer half-life and greater affinity for melatonin receptors and consequently are thought to hold promise for treating a variety of circadian disruptions. We will trial these agents for the next international tour.

Mike Cadogan is a physician in Australia who blogs at Life in the Fast Lane.

Technorati Tags: Jet Lag, Melatonin

By Fran Lowry

NEW YORK (Reuters Health)  - Infants and children being treated with narcotics routinely receive overdose amounts, according to a study presented in Denver this past weekend at the annual meeting of the Pediatric Academic Societies (PAS).

Narcotics are usually given to young children in liquid formulations, which are difficult for parents to measure correctly. Also, pharmacists may not account for the child’s weight when prescribing, said Dr. William T. Basco, Jr, from the Medical University of South Carolina in Charleston.

“Narcotics involve a large proportion of drugs that are most commonly involved in adverse drug events and we also know that parents have problems properly measuring liquid preparations, so taking those two factors together, we wanted to find out more about the frequency of potential overdoses in young children,” Dr. Basco told Reuters Health.

He and his colleagues identified the top 19 narcotic-containing drugs prescribed for children aged 0-36 months from a review of 2000-2006 South Carolina outpatient Medicaid data. They calculated the expected daily dose of the narcotic based on Centers for Disease Control and Prevention growth chart data to impute the weight of each child as the 97th percentile based on age and gender, and then compared that dose with the actual amount of narcotic dispensed by the pharmacy.

During that time, there were 149,791 prescriptions for narcotic-containing preparations, for patients with a mean age of 18 months.

“Most of these prescriptions were appropriate, for post-operative or post-trauma pain. Some were for antitussants, and I think that is an important point to emphasize,” Dr. Basco said.

Fifteen percent of the prescriptions contained an overdose quantity of narcotic, the research team found. The average excess amount of narcotic dispensed was 53% more than expected.

The researchers also found that the younger the children, the more frequent the overdoses. More than half (61%) of infants aged 0 to 2 months who received a narcotic got an overdose, compared with 35% of infants 3 to 5 months old, 17% of infants 6 to 11 months old, and 8% of children 12 months or older (p<0.0001).

Younger children also got larger overdoses. Compared to expected doses, actual doses were 90% higher in the 0 to 2 month age group, 53% higher in the 3 to 5 month group, 36% higher in the 6 to 11 month set, and 34% higher for babies 2 months and older (p<0.05).

In addition, the youngest infants were dispensed more than twice the expected quantity 20% of the time. In comparison, infants 3 to 5 months got more than twice the expected quantity 3.8% of the time, infants 6 to 11 months, 1.5% of the time, and for children 12 months or older, it was just 0.2% of the time (p < 0.05).

“Clinicians need to remember that the younger the child, even small deviations from the appropriate dose will make a big difference,” said Dr. Basco. “Giving 20% more drug when you are 5, 6, or 10 years old doesn’t matter as much, but when you are a 2-month-old, then it matters a lot.”

The sedative effects of the narcotics can cause young children to stop eating and drinking and become dehydrated. “Very few would die from overdose but that is possible, but the greater issue is dehydration and this is harmful,” Dr. Basco said.

He added that, ideally, all pediatric prescriptions should be based on the child’s weight.

“For inpatients, our hospital pharmacy will not send any drugs to the floor unless the child’s weight is on the order, but ambulatory prescriptions that you get at Walgreens or CVS do not consider the child’s weight,” Dr. Basco added.

Click here to read the rest of this article.

Technorati Tags: Children, Drug Overdose, Infant, Medicine, Narcotic, Overdose

IQware MTM photo

Outcomes Pharmaceutical Health Care and Security Health Plan of Wisconsin today announced ground-breaking Medication Therapy Management (MTM) program results. . In the evaluation, Security Health Medicare members receiving MTM services from local pharmacists resulted in, on average, over $600 per member in overall cost savings annually. Commercial members receiving the services resulted in over $500 in savings per year. Savings specific to drug product costs exceeded $200 per member, on average, within both the Medicare and commercial populations. This first-of-its-kind evaluation included over 100,000 members. . “While current requirements for MTM services exist only in Medicare, as a health plan we understand the strategic importance of these services for our entire membership,” said Twila Johnson, Director of Pharmacy Services. “The results confirm the key role local pharmacists can play in assisting members and prescribers to optimize medication therapy.” . Outcomes identifies medication treatment gaps and works with local pharmacists and prescribers to close these gaps, reducing drug costs and improving adherence. Security Health is one of over 30 US health plans that have adopted the Outcomes unified MTM platform which connects such plans with 39,000 chain, independent, consultant and health-system pharmacy providers across the country. . Program results will be reported at the Academy of Managed Care Pharmacy (AMCP) Annual Meeting in Minneapolis, Minnesota on Friday, April 29. . Click here for more information about MTM > Medication Therapy Management from the American Pharmacists Association.

Technorati Tags: Medication Therapy Management, MTM

Technorati Tags: Drug Side Effects, Medicine, Medicine Diary, Patient Package Insert, pharmacist, pharmacy

• Allegra® 24-hour and 12-hour tablets for adults and children 12 and older
• Children’s Allegra® 12-hour tablets for children ages 6 years and older
• Allegra® Liquid for children ages 2 years and older
• Children’s Allegra® 12-hour ODT for children ages 6 years and older
• Allegra-D® 24-hour and 12-hour allergy and congestion extended release tablets for adults and children 12 years and older

Technorati Tags: Allegra, allergy, allergy medicine, antihistamine, cetirazine, loratadine, OTC

By Mayo Clinic staff

Sleeping on your side

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By making simple changes in your sleeping position, you can take strain off your back. If you sleep on your side, draw your legs up slightly toward your chest and put a pillow between your legs. Use a full-length body pillow if you prefer.

This position may be particularly helpful if you have osteoarthritis in the spine, spinal stenosis — a narrowing in the spine — or hip pain.

Sleeping on your back

If you sleep on your back, place a pillow under your knees to help maintain the normal curve of your lower back. You might try a small, rolled towel under the small of your back for additional support. Support your neck with a pillow.

This position may be helpful if you have low back pain.

Sleeping on your abdomen

Sleeping on your abdomen can be hard on your back. If you can’t sleep any other way, reduce the strain on your back by placing a pillow under your pelvis and lower abdomen. Use a pillow under your head if it doesn’t place too much strain on your back. If it does cause strain, try sleeping without a pillow under your head.

This position may be helpful if you have degenerative disease or a herniated disk in the central portion of your spine.

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• See Also

• Back pain relief: Ergonomic chair or fitness ball?
• Slide show: Prevent back pain with good posture

Technorati Tags: Back Pain, Back Pain Relief, Sleeping Positions

Call 911 and start doing chest compressions immediately

Click here to watch this five minute video and then you will know what to do if someone appears to be having a heart attack.

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Evey minute you delay beginning CPR, lessens their chance of surviving by 10 percent.  If you wait 5 minutes their chance of survival has already dropped to 50 percent or less.

“Sarver Heart Center’s newest video makes it easy to learn Continuous Chest Compression CPR. Every three days, more Americans die from sudden cardiac arrest than the number who died in the 9-11 attacks. You can lessen this recurring loss by learning this hands-only CPR method that doubles a person’s chance of surviving cardiac arrest.  Watch physician researchers Gordon A. Ewy, MD, and Karl Kern, MD, demonstrate the easy, life-saving method that they developed at the University of Arizona College of Medicine.”

Click here to learn how easy it is to administer life-saving Sarver Chest Compressions

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Technorati Tags: Continuous Chest Compression, CPR, Heart Attack, Sarver Heart Center, Save a life

Friends for Life - Manatanka.org image

by Danielle Leach, MPA

“A true friend walks in when everyone else walks out.”

I read that on a magnet on my friend’s refrigerator recently and the simple power of that saying brought me to tears. I have learned that lesson of true friends since my son’s diagnosis of cancer in 2007.

Anyone who has faced a serious illness as a patient or a caregiver knows that you quickly learn who your friends are. They are the ones who are there, who listen instead of trying to fix things, who are present for you in any way you need them. Some people you love will disappoint and not rise to the occasion, and some people you never expected will be your biggest supporters.

It is hard not to resent people who are there in the crisis, and then leave once the immediate crisis is over. There are people who are not there for the long haul, for the good and the bad that a disease may bring. The initial drama draws everyone in, but sends them running afterward.

I have learned, especially when you are living a nightmare, that it takes a special person to stay with you throughout the crisis. A person who keeps checking in and knows the journey is not necessarily over once you are in remission, or when your loved one has passed away. When my son Mason had brain cancer, our family found our true friends. We were surprised by many who walked out, but also by how many true friends walked into our lives because of Mason’s illness. We have learned even after Mason’s death, even three years later, we continue to go through this process of discovering our true friends.

Some people are not capable of handling personal difficulties. We, as patients and caregivers, need to understand not everyone has the capacity or tools to handle a crisis of another. This knowledge does not make it any easier for us as we wade through process of dealing with disease.  As a director at Inspire, a company that creates and manages online patient support communities, I see regularly the comments of patients and caregivers who talk about friendships won and lost since diagnosis. Some are surprised and profoundly saddened by the lack of support from those expected to help the most. However, many happily note those friends, family, and even strangers who surprise them with support in a time of great need.

I recall reading about a Florida woman, whose teenage son was undergoing chemo, wrote that her friends avoided her upon learning about her son’s cancer diagnosis. “It’s almost like they were afraid they could catch it,” she said.

Another, a bladder cancer survivor from New Jersey, observed, “A lot of people walk out. . . a good 50% of my ‘pre-cancer’ friends I have never heard from again.” He went on to say, “In my case, I am lucky. I have all strong ones, having cut weak relations a long time ago. I keep only the cream of the crop.”

Sometimes finding others who are dealing with the same issues can be the most helpful strategy. You can often talk online more frankly and honestly with them than with some loved ones or friends. Dealing with an illness can be a lonely and scary process. Participating in support communities often help alleviate some of that loneliness. I have seen repeatedly how these connections are a powerful tool and establish strong personal friendships among members.

If you’re a patient or caregiver, look for the people who are true friends and hold those people close. Craft a strong support network–both in person and online. If you have a chance to do so, be the kind of true friend people are often searching for in their lives when they need it the most.

Danielle Leach is Director of Partnerships at Inspire and is founder of the Mason Leach Superstar Fund, in memory of her son, Mason, who died of pediatric medulloblastoma in 2007.

Technorati Tags: Cancer, Caregiver, Therapy, True_Friends, True_Friendship

by Christopher Johnson, MD

When it comes to football season,  it’s time to think about sports injuries. We frequently have children admitted to the PICU (or to what we call the intermediate or step-down unit) for observation, typically overnight, who have struck their head. They have had concussions. What is a concussion, and what does it mean for the child?

The term itself is centuries old, but even thirty-five years ago, when I was in training, the actual definition of concussion was a bit vague. What was usually meant was that the patient got hit on the head and either lost consciousness briefly or at least wasn’t quite himself for some period of time afterward. These days we’re more precise than that, but concussion is still a somewhat inexact term. This is mainly because of our ignorance of the subtleties of how the brain works.

The formal definition of concussion is a transient interruption in brain function. By implication, various scans of the brain, such as CT scans or MRI scans, show no abnormalities. Since all the imaging studies are normal, defining concussion is necessarily inexact. I’m sure one day we’ll have some kind of machine that detects the reason for the symptoms of concussion, but right now we don’t have such a thing — concussion is an entirely clinical diagnosis, meaning there’s specific no test for it.

There are several systems for grading concussions. Here’s how the American Academy of Neurology grades their severity:

Grade I: confusion, no loss of consciousness, symptoms last for < 15 minutes, has memory of the event
Grade II: confusion, may lose memory of the event but no loss of consciousness, symptoms last for > 15 minutes
Grade III: loss of consciousness and no memory of the event

The list of symptoms that can come from a concussion is a long one. Headache, dizziness, vomiting, and ringing in the ears are common. Various behavioral changes are also common, such as lethargy, difficulty concentrating, and irritability.

What are the effects of concussion on a child? Years ago we pooh-poohed the idea that mild concussions cause brain problems. For example, football players were sent right back into the game after experiencing a concussion. We now know that is dangerous. As a general rule, we don’t recommend any contact sports for at least a week (some authorities say longer) after all symptoms have cleared. This is because a repeat blow to the head, even a very mild one, can cause severe injury to a brain that has not fully recovered from the last injury.

What about long term effects of concussions? The overwhelming majority of children who suffer a concussion, especially a mild one, recover completely. But around a fifth or so of children who have had severe concussions continue to have problems many months afterward.

You can read much more about concussions at the federal Centers for Disease Control, the Mayo Clinic, and the respected Brain Trauma Foundation.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

Technorati Tags: Brain, Children, Concussion, Pediatric, Sports Injury