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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

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by dr_som, MD

I love to pick up my two year old from daycare. Her language is becoming increasingly complex with small sentences, lots of gesturing and expression. When I ask how school was, she says, “Miss you. I crying.” Or, “I running fast with friends.” Or sometimes a confident, “good,” with a head nod.

Yesterday, she said, “friend, bite me.”

Her very kind teacher confirmed the event, and asked my daughter to show me the mark. No broken skin. No big deal. I reassured the teacher. I signed the incident form.

My daughter told me, “Miss Jean hold me and wash it. Tommy time out.”

I continue to marvel at the calm and skill of good daycare teachers. Miss Jean provided the proper hygiene, comfort, and discipline without yelling or blaming. I did not even ask what lead up to the incident because it did not matter. Asking my daughter why Tommy bit her would serve no purpose. Biting is never justified, and how can she speculate about what he was thinking.

I wanted her to learn forgiveness. I said, “You bite mommy and daddy sometimes. I bet he said sorry. You are OK. He’ll use his words next time.”  She nodded yes.

When infants mouth objects, we think nothing of it. Parents know it is normal for children to put things in their mouths. Most children start this oral behavior around 4 months of age and stop anywhere from 9 to 18 months with the behavior becoming less frequent as they learn more about the world through other methods. Biting other children or adults begins when chewing on other objects slows. Around this same time children are increasingly aware of social behaviors and are both curious and a little anxious about interacting with other people.

Biting is very natural and all children around the age of 12 months begin to experiment with biting Mom or Dad. Then they might try biting siblings or friends. The behavior peaks around 24 months and then declines. Three year old children rarely bite because they have gained social competence and the language skills to mediate frustration.

Please know that all children bite. No matter how you handle the behavior, your child will outgrow it by three years old. How you react may affect how quickly the behavior stops.

To nip it in the bud

• A simple, “biting hurts” will do. Nobody should be called bad. No shouting.
• Give affection and attention to the child that was bitten.
• Briefly ignore the biter. Time out may not be necessary as ignoring the child sends a clear message that biting is an antisocial behavior.
• Let the biter say sorry or hug the person he has hurt.
• Anticipate biting and offer distraction or offer words that the child can use instead.
• If the skin is broken, see your doctor about the need for antibiotics or a tetanus shot. Usually soap, lots of water, and maybe a cool compress are all you need.
• Choose a daycare with good staffing ratios, at least one adult to four children for toddlers. A quality provider engages the children, minimizes boredom, recognizes fatigue and understands that biting happens.

Biting is almost never a sign of abnormal development in an otherwise normal child. My autistic child never bit anyone, but my five year old used to and my two year old still does.

Biting is a sign of normal social experimentation. I just hope I can keep that in mind when my daughter comes home with her first hickey.

“dr_som” is a pediatrician who blogs at Pensive Pediatrician.

Technorati Tags: Biting, Parenting

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.

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

by Mayo Clinic Staff

Get the facts about these common fibromyalgia myths. Learning all you can about fibromyalgia is the first step toward gaining control of your symptoms.

Fibromyalgia is a widely misunderstood condition that causes widespread pain and fatigue. If you’ve been diagnosed with fibromyalgia and are trying to learn all you can about the condition, you may come across some myths and misconceptions about fibromyalgia.

In this interview, Connie Luedtke, R.N., the nursing supervisor of the Fibromyalgia and Chronic Fatigue Clinic at Mayo Clinic, Rochester, Minn., answers questions about some of the most common misconceptions about fibromyalgia.

What is the most common misconception about fibromyalgia?

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The top misconception is that people think fibromyalgia isn’t a real medical problem or that it is “all in your head.” It’s sometimes thought of as a “garbage-can diagnosis” — if doctors can’t find anything else wrong with you, they say you have fibromyalgia. Being diagnosed with fibromyalgia does require that you meet specific criteria, including painful tender points above and below the waist on both sides of the body.

There’s a lot that’s unknown about fibromyalgia, but researchers have learned more about it in just the past few years. In people who have fibromyalgia, the brain and spinal cord process pain signals differently; they react more strongly to touch and pressure, with a heightened sensitivity to pain. It is a real physiological and neurochemical problem.

Click here to read the rest of this article on fibromyalgia misconceptions from the Mayo Clinic.

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X-ray of Patient with Tuberculosis

This report summarizes provisional 2010 data from the National TB Surveillance System and describes trends since 1993.

Despite an average decline in TB rates of 3.8% per year during 2000–2008, a record decline of 11.4% in 2009 (2), and the 2010 decline of 3.9%, the national goal of TB elimination (defined as <0.1 case per 100,000 population) by 2010 was not met (3).

Although TB cases and rates decreased among foreign-born and U.S.-born persons, foreign-born persons and racial/ethnic minorities were affected disproportionately by TB in the United States.

In 2010, the TB rate among foreign-born persons in the United States was 11 times greater than among U.S.-born persons. TB rates among Hispanics, non-Hispanic blacks, and Asians were seven, eight, and 25 times greater, respectively, than among non-Hispanic whites. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates was for non-Hispanic blacks, whose rate was seven times greater than the rate for non-Hispanic whites.

Progress toward TB elimination in the United States will require ongoing surveillance and improved TB control and prevention activities to address persistent disparities between U.S.-born and foreign-born persons and between whites and minorities.

Click here to read the complete article. Trends in Tuberculosis

Technorati Tags: TB, TB Rate, Tuberculosis

• 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

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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