Tuesday, July 21, 2009

Vaccines for immunization

Vaccines
The 2009 recommended immunization schedules have been issued for children aged 0 to 6 years , 7 to 18 years , and children who are behind on immunizations . Major changes include the recommendation for annual influenza immunization for all children aged 6 months to 18 years and increased upper age limits for rotavirus vaccine.Reports of invasive Haemophilus influenzae type b (Hib) disease in five children in Minnesota highlights the importance of completion of the primary series of Hib vaccines by seven months of age . The combination dipththeria-tetanus-acellular-pertussis/inactivated polio/Hib vaccine may be used for any and all doses of the primary series.

Pediatric otolaryngology

Pediatric otolaryngology
In a randomized trial of dexamethasone versus placebo in 215 children undergoing tonsillectomy, dexamethasone was beneficial in reducing postoperative nausea and vomiting, but was associated with increased risk of bleeding requiring reoperation .Suboptimal levels of vitamin D were found in 95 percent of patients with cystic fibrosis, although most were taking fat-soluble vitamin supplements . Vitamin D deficiency contributes to the bone disease associated with cystic fibrosis, characterized by decreased mineral density, increased fracture rates, and kyphosis.

Pediatric neurology

Pediatric neurology
The need for lumbar puncture in the evaluation of infants after a first simple febrile seizure has been questioned by findings from a review of cerebrospinal fluid results . Among 268 patients aged 6 to 18 months who had a lumbar puncture after a first simple febrile seizure, no diagnoses of bacterial meningitis were made

Pediatric nephrology

Pediatric nephrology
In the fall of 2008, over 52,000 Chinese infants developed kidney stones because of exposure to melamine-contaminated powered infant formula [74] . Acute renal failure (ARF) due to urinary obstruction was common and there were four reported deaths. The Sanlu product that has been incriminated in these cases had a concentration of melamine that resulted in a 100-fold greater intake of melamine than the tolerable daily intake of 0.5 mg/kg newly established by the US Food and Drug Administration .

Pediatric neonatology

Pediatric neonatology
The American Academy of Pediatrics (AAP) published discharge guidelines for infants cared for in the neonatal intensive care unit to ensure smooth transition home and prevent premature discharge .A trial of routine insulin therapy started within 24 hours of birth in very low birth weight infants (< 1500 g) found higher mortality rates compared to standard care .Preterm infants who received surfactant therapy and continuous positive airway pressure (CPAP) were less likely to require mechanical ventilation or develop bronchopulmonary dysplasia than those who received only CPAP therapy

General Pediatrics

General pediatrics
In children with asymptomatic inguinal hernias, longer waiting time for elective surgery is associated with increased risk for incarceration, especially in infants less than one year of age. An observational study found that a wait time that exceeded 14 days from the time of diagnosis was associated with an absolute increase of 7 percent (12 versus 5 percent) in the occurrence of incarceration in infants and children <1 year of age .The American Academy of Pediatrics (AAP) suggests that infant cereals and puréed meats be offered to infants as the initial solid foods rather than puréed fruits and vegetables [59] . Infant cereals and pureed meats provide iron and zinc, which are the nutrients most likely to be deficient in the diets of infants in the United States.Gestation appears to be a critical period for determining obesity predisposition and metabolic outcomes in offspring, a process termed "metabolic programming". A study found a lower prevalence of obesity in children born to women who had gastric bypass surgery than siblings who were born before gastric bypass .Optimal management for acute virus-induced wheezing in preschool children is uncertain. A five-day course of oral prednisolone in hospitalized preschool children with acute mild to moderate virus-induced wheezing did not shorten hospital stay, reduce albuterol use, or improve symptom scores in a multicenter randomized trial .

Urogynecology

Urogynecology
The US Food and Drug Association issued a public health notification regarding serious complications associated with intravaginal mesh placement using trocars or other tools for repair of pelvic organ prolapse or stress urinary incontinence . Reported complications include mesh erosion, infection, pain, treatment failure, and urinary problems.

Gynecologic Surgery

Gynecologic surgery
A case series of 6000 Essure® hysteroscopic sterilizations reported 10 pregnancies . Risk factors for post-procedure pregnancy included lack of confirmation of tubal occlusion and micro-inserts that were placed unilaterally, or expelled, or perforated the uterus or tube.

Reproductive endocrinology

Reproductive endocrinology
Whether assisted reproductive technology is an independent risk factor for development of cerebral palsy remains unclear. A meta-analysis found the risk of cerebral palsy was doubled in children who were conceived with IVF technology . However, the increased risk of cerebral palsy appeared to be mediated by the high frequency of low birth weight/preterm birth and multiple gestation in the IVF groupObesity-related hormonal changes in overweight men appear to adversely affect sperm parameters and may cause erectile dysfunction . The effect of weight loss on sperm parameters and pregnancy rate has not been studied.

Office Gynecology

Office gynecology
The location, and not size, of a fibroid, is the principal factor impacting fertility. A meta-analysis found that women with fibroids that distort the uterine cavity were at increased risk for infertility and spontaneous abortion . Myomectomy increased the conception rate but did not decrease the risk of miscarriage.The World Health Organization revised several tables regarding criteria for contraceptive use. There are no longer restrictions on placement of the levonorgestrel-releasing intrauterine device in the first 48 hours after delivery in nonbreastfeeding women.

Obstetrics

Obstetrics
A randomized trial found that women at risk for preterm birth who received a single course of antenatal glucocorticoids had better birth outcomes than women who received repeated glucorticoid courses every two weeks .A large prospective cohort study found that repeat cesarean delivery scheduled during the 39th or 40th week of gestation was associated with the lowest rates of adverse neonatal outcome, compared to earlier or later scheduled delivery .

Rheumatology Primary Care

Primary care rheumatology
A systematic review found that arthrographic distension (intraarticular dilation or hydroplasty) of the glenohumeral joint reduced pain and improved short-term function in patients with adhesive capsulitis .A meta-analysis in patients with fibromyalgia found that antidepressant therapy improved pain, fatigue, mood, sleep, and health-related quality of life . The effect size was greatest with tricyclic antidepressants but there were no trials directly comparing antidepressants.

Pulmonology Primary Care

Primary care pulmonology
A meta-analysis found that inhaled glucocorticoids in patients with COPD increased the risk of pneumonia by about 30 percent .Smoking prevalence fell among men and women from 1975 to 2006 . This was accompanied by a decline in the death rate for lung cancer among men and a leveling off of the death rate for lung cancer among women

Oncology Primary Care

Primary care oncology
The age at which breast cancer screening should commence in known BRCA mutation carriers is unclear. Women at high genetic risk for breast cancer may also be more susceptible to radiation-induced carcinogenesis. A pooled analysis that estimated the lifetime risk of radiation-induced breast cancer from annual mammography in young BRCA mutation carriers concluded that the harms of annual screening would outweigh benefits in women ages of 25 to 29, and probably between ages 30 and 34 as well .

Neurology Primary care

Primary care neurology
A large controlled trial has confirmed earlier data that bilateral deep brain stimulation is superior to medical treatment in selected patients with advanced Parkinson disease and motor fluctuations . However, the benefit comes at the cost of an increased risk of complications related to surgery.The largest double-blind trial evaluating the treatment of Bell's palsy confirmed that early oral glucocorticoid treatment was effective, while antiviral therapy was not .

Nephrology and Hypertension Primary Care

Primary care nephrology and hypertension
A large randomized trial of combination therapy for hypertension in patients at high risk for cardiovascular complications found that in patients receiving an ACE inhibitor, cardiovascular event rates were lower with amlodipine compared with hydrochlorothiazide (HCTZ) . Given these results and earlier results showing that outcomes with chlorthalidone were at least as good as with amlodipine, we suggest that patients who are started on a thiazide diuretic for hypertension be treated with chlorthalidone rather than HCTZ.A meta-analysis involving 1193 patients undergoing surgery found that N-acetylcysteine, compared with placebo, failed to provide benefit in preventing acute kidney injury .

Infectious Disease Primary Care

Primary care infectious disease
In a lookback investigation of 1669 patients who had been operated on by an HIV-infected cardiothoracic surgeon, 33 percent underwent serologic testing for HIV and none were seropositive . These data continue to support the view that the risk of HIV transmission from an HIV-infected health care worker is extremely low.The United States Advisory Committee on Immunization Practices (ACIP) has issued guidelines stating that HPV vaccine should not be withheld from females up to age 26 years despite a history of genital warts, abnormal Papanicolaou tests, or positive HPV DNA tests .The ACIP added cigarette smoking and asthma as indications for vaccination of adults with the pneumococcal vaccine (PPV23; Pneumovax) .The CDC has updated TB diagnosis guidelines to include nucleic acid amplification (NAA) sputum testing. Patients meeting clinical criteria for TB should undergo chest radiography; if suggestive of TB, three sputum specimens for AFB smear and culture should be obtained. At least one specimen should also be tested using a nucleic acid amplification (NAA) test if available .There has been a dramatic rise in the rate of oseltamivir-resistant H1N1 influenza A worldwide, with resistance identified in 97 percent of H1N1 influenza virus isolates tested from 30 states in the United States between October 2008 and January 2009 [40] . All isolates were sensitive to zanamivir, amantadine, and rimantadine.

Hematology Primary Care

Primary care hematology
A study found that patients with a low probability result on a clinical score (the "4 T's" test) for heparin-induced thrombocytopenia (HIT) were at low enough risk that laboratory testing for HIT antibodies was probably not required .

Gastroenterology Primary care

Primary care gastroenterology
Oral bisphosphonates have been linked to esophageal adenocarcinoma and squamous cell carcinoma according to a post-marketing US Food and Drug Administration (FDA) letter . The FDA recommends that oral bisphosphonates not be used in patients with Barrett's esophagus.A randomized trial compared a "step down" with a "step up" approach (ie, beginning with antacids and advancing to H2 receptor antagonists and then proton pump inhibitors) in patients with new onset dyspepsia seen in the primary care setting . After six months, the success rates were similar but the step-up approach was associated with lower overall costs.

Adult Medicine- latest

ADULT MEDICINE
General internal medicinePreventionThe JUPITER trial, a randomized trial of rosuvastatin therapy in healthy men (age ≥ 50) and women (age ≥ 60) with an LDL-C level <130>500 ms; frequent monitoring for QTc 450-500 ms; and avoiding other drugs that prolong the QT or slow methadone elimination .A population-based study evaluated risk factors for unintentional overdose fatality related to prescription drug abuse . Pharmaceutical diversion was associated with 67 percent of deaths.UrologyA randomized trial found no benefit for use of an alpha blocker to treat pain in men with chronic prostatitis/chronic pelvic pain syndrome .Primary care cardiologyThe 2008 POISE trial raised concerns about the use of beta blockers in noncardiac surgery. A subsequent meta-analysis of beta blocker therapy evaluated outcomes in >12,000 patients, including >8000 from POISE . Beta blocker therapy reduced the risk of myocardial infarction (MI) by one-third while more than doubling the risk of stroke, and had no significant effect on all-cause or cardiovascular mortality.A large case-control study in patients receiving clopidogrel after an MI found an association between use of proton pump inhibitors (PPIs) and recurrent MI . PPIs may reduce the effectiveness of clopidogrel in inhibiting platelet function . We no longer recommend routine prophylactic PPI therapy for low risk patients taking clopidogrel and aspirin.In a large randomized trial, irbestan treatment for patients with symptomatic heart failure and a preserved ejection fraction did not improve the primary end point of death from any cause or hospitalization for a cardiovascular cause.Three multicenter studies evaluated the accuracy of 64-slice multidetector computed tomography coronary angiography for detection of coronary artery disease . Sensitivity varied from 95 to 85 percent and specificity varied from 90 to 64 percent.Primary care endocrinologyIn a randomized trial in patients with poorly-controlled type 2 diabetes, there was no difference in cardiovascular outcomes between the intensive (achieved A1C 6.9 percent) and standard (A1C 8.4 percent) groups .In a trial of patients with type 2 diabetes randomly assigned to a low-glycemic index or a high-cereal fiber diet, there was a modest difference in A1C decline from baseline favoring the low-glycemic index group .Updated guidelines for the management of asymptomatic primary hyperparathyroidism recommend parathyroid surgery in patients with a serum calcium 1.0 mg/dL (0.25 mmol/L) above the normal limit, creatinine clearance <60 ml/min, bone density T-score < -2.5, or age <50 years .

Friday, July 17, 2009

Valvular and Aortic Disease

VALVULAR AND AORTIC DISEASE
The Ross procedure (pulmonary autograft) is an alternative to mechanical or bioprosthetic aortic valve replacement that continues to be offered to children and adults under 50 years of age at certain experienced centers. A meta-analysis of Ross procedure series published from 2000 to 2008 revealed generally good short and long term survival rates for experienced centers but ongoing limitations in the durability of the autograft and the right ventricular conduit .

Congenital Heart disease- Latest

CONGENITAL HEART DISEASE
The American College of Cardiology (ACC)/American Heart Association (AHA) published guidelines for the management of adults with congenital heart disease . We agree with the guideline recommendation that patients with Eisenmenger syndrome avoid the following conditions or activities which are associated with increased risks: pregnancy, dehydration, moderate and severe strenuous exercise, acute exposure to excessive heat, chronic high-altitude exposure, and iron deficiency.

Peripheral artery disease - Latest

PERIPHERAL ARTERIAL DISEASE
While exercise rehabilitation has been shown to be of value in patients with symptomatic peripheral arterial disease, such benefit has not been established in asymptomatic patients. In a randomized trial (N = 156) treadmill exercise increased the distance walked by 36 meters during a six minute walk test .

Non Invasive Imaging - Latest

NONINVASIVE IMAGING
The 2008 American Society of Echocardiography consensus statement on contrast agents in echocardiography reviewed safety considerations and clinical applications for contrast echocardiography including use in assessment of left ventricular structure and function.Three multicenter studies evaluated the diagnostic accuracy of 64-slice multidetector computed tomography coronary angiography for detection of coronary artery disease defined as ≥ 50 percent stenosis on quantitative invasive coronary angiography . For patient-based analysis, sensitivity varied from 95 to 85 percent and specificity varied from 90 to 64 percent. .Risk stratification by SPECT radionuclide myocardial perfusion imaging and renal function was evaluated in 1652 patients . Both chronic kidney disease and abnormal test result (scar or ischemia) were independent predictors of cardiac death after accounting for risk factors, left ventricular dysfunction, pharmacological stress, and symptom status

LATEST IN CORONORY HEART DISEASE

CORONARY HEART DISEASE
The POISE trial published in 2008 raised important concerns about the use of beta blockers in patients undergoing noncardiac surgery. A subsequent meta-analysis of 33 randomized trials of beta blocker therapy evaluated outcomes in over 12,000 patients, of whom over 8000 were from POISE . Beta blocker therapy was not associated with a significant reduction in the risk of either all-cause or cardiovascular mortality.Patients with heterozygous familial hypercholesterolemia have a poor prognosis and aggressive lipid lowering therapy is indicated in most. Although the combination of ezetimibe plus simvastatin lowers low density lipoprotein cholesterol to a greater extent than monotherapy with simvastatin and has been shown to be safe , one study of adolescents with heterozygous FH did not demonstrate that the combination improved arterial intima-media thickness to a greater degree than a similar dose of simvastatin monotherapy during up to 53 weeks of therapy .Statins have many (pleiotropic) effects which may be both clinically important and independent of their well established low density lipoprotein cholesterol lowering ability. In a trial of 60 patients with dyslipidemia, who were randomly assigned to high dose simvastatin or a combination of ezetimibe with lower doze simvastatin, both groups had similar 35 to 40 percent reductions in LDL-C and serum CRP. However, a significant improvement in flow-mediated dilatation was only seen in the high-dose simvastatin group .While no randomized trial data are available to compare open surgery with endovascular repair of the thoracic aorta (TEVAR), recent observational studies and one meta-analysis support equivalent or better outcomes with the latter .Evidence suggests that the oral antiplatelet agent prasugrel will be an important addition to the long term management of patients who have sustained an acute non-ST elevation myocardial infarction. Compared to clopidogrel, death rates after a first ischemic event and recurrent events are less with prasugrel .The issue of whether the use of clopidogrel within five days of coronary artery bypass surgery increase the risk of important perioperative bleeding has been controversial. Recent publications do not definitively answer this question.Free wall rupture after acute myocardial infarction has a poor prognosis. One study suggests that the incidence of this complication has fallen over the past forty years from about four to two percent and that the associated mortality has also fallen . A progressive increase in the use of reperfusion therapies and medical therapies such as beta blockers, angiotensin-converting enzyme inhibitors and aspirin, as well as better control of blood pressure with each subsequent decade were also noted.The JUPITER trial, a randomized trial of rosuvastatin therapy in healthy men (aged 50 and older) and women (aged 60 and older) with an LDL-C level below 130 mg/dL (3.4 mmol/L) and a C-reactive protein (CRP) level of at least 2.0 mg/L, found a large reduction in the primary composite cardiovascular endpoint (hazard ratio 0.56) . The magnitude of this reduction was greater than might have been expected from prior trials and may have been overestimated when the trial was stopped early for benefit. Although some have interpreted this trial as showing particular benefit in patients with an elevated CRP level, the design did not allow evaluation of whether a similar relative benefit might have been seen in patients with lower CRP levels or whether measuring CRP added information beyond standard risk calculation. In primary prevention, we suggest first calculating a patient's baseline risk for cardiovascular events and then treating with statin therapy in patients for whom a 20 to 30 percent relative reduction in events would translate into an absolute risk reduction large enough to be of value to the patients.In a study of 13,636 patients prescribed clopidogrel following acute myocardial infarction, investigators identified 734 cases readmitted with myocardial infarction and 2057 controls. On multivariate analysis, current use of proton pump inhibitors (PPI) was associated with a significantly increased risk of reinfarction . This finding was observed in other preliminary clinical studies. In addition reports of decreased effectiveness of clopidogrel in inhibiting platelet function in the presence of PPI have been observed . Based upon these findings, we no longer recommend PPI therapy for all patients on clopidogrel and aspirin.

LATEST IN ARRYTHMIA

ARRHYTHMIAS
The choice between rhythm control and rate control for patients with atrial fibrillation (AF) and heart failure can be challenging. In a trial of 81 patients with class II or III heart failure and symptomatic, drug-refractory atrial fibrillation (AF), ablation of the AF focus via pulmonary vein isolation (PVI) resulted in significant improvements in LVEF, exercise capacity, and symptoms compared with a rate control strategy employing AV node ablation and biventricular pacing .Myocardial infarction and pulmonary embolus are common causes of sudden cardiac death, and this has raised the question of whether fibrinolytic therapy should be incorporated into the cardiopulmonary resuscitation (CPR) protocol for cardiac arrest. A randomized placebo-controlled trial of 1050 patients with witnessed out-of-hospital cardiac arrest failed to show significant survival benefit of tenecteplase administered during CPR.Several antipsychotic medications block the cardiac myocyte's repolarizing potassium currents and prolong the QT interval. Their widespread use (including for conditions such as dementia, agitation, and affective disorders) and the potential for sudden death from torsades de pointes has led to concerns about the safety of these agents. Although "typical" antipsychotic drugs such as haloperidol and thioridazine have received much attention, a large retrospective cohort study found that treatment with "atypical" antipsychotics similarly increased the risk of sudden death in patients with psychosis .

Tuesday, July 14, 2009

CESAREAN DELIVERY

INTRODUCTION — A cesarean delivery (also called a surgical birth) is a surgical procedure used to deliver an infant. It requires regional (or rarely general) anesthetic to prevent pain, and then a vertical or horizontal incision in the lower abdomen to expose the uterus (womb). Another incision is made in the uterus to allow removal of the baby and placenta. Other procedures, such as tubal ligation (sterilization), may also be performed during cesarean delivery
Cesarean deliveries may be performed because of maternal or fetal problems that arise during labor, or they may be planned before the mother goes into labor. More than 30 percent of births in the United States occur by cesarean delivery.
REASONS FOR CESAREAN DELIVERY — Some women who intend to deliver vaginally will eventually require cesarean delivery. Reasons for this include the following: Labor is not progressing as it should. This may occur if the contractions are too weak, the baby is too big, the pelvis is too small, or the baby is in an abnormal position. If a woman's labor does not progress normally, the first step is usually to rupture her membanes (bag of water). In many cases, the woman will be given a medication (Pitocin®/oxytocin) to be sure that contractions are adequate for several hours. If labor still does not progress after several hours, a cesarean delivery may be recommended. The baby's heart rate suggests that it is not tolerating labor well. This may be due to a placental problem or compression of the umbilical cord. The baby is in a sideways or breech position (buttocks first) when labor begins. Heavy vaginal bleeding. This can occur if the placenta separates from the uterus before the baby is delivered (called a placental abruption). A medical emergency threatens the life of the mother or infant
PLANNING CESAREAN DELIVERY — A planned cesarean delivery is one that is recommended because of the increased risk(s) of a vaginal delivery to the mother or her infant. Cesarean deliveries that are done because the woman wants, but does not require, a cesarean delivery are called "maternal request cesarean deliveries". There are a number of medical and obstetric circumstances that a healthcare provider would recommend scheduling a cesarean delivery in advance, including the following: The mother has had a previous cesarean delivery or other surgery in which the uterus was cut open. A vaginal delivery is possible after cesarean delivery in some, but not all cases. There is some mechanical obstruction that prevents or complicates vaginal delivery, such as large fibroids or a pelvic fracture. The infant is unusually large, especially if the mother is diabetic. The mother has an active infection, such as herpes or HIV, that could be transmitted to the infant during vaginal delivery. The birth involves multiple gestation (twins, triplets, or more). The woman has cervical cancer. The infant has an increased risk of bleeding. The placenta is covering the cervix (called placenta previa).
There is some controversy about the preferred method of delivery in certain situations. These include some birth defects, such as spina bifida and fetal abdominal wall defects, and some maternal medical problems.
One of the most important factors in scheduling a cesarean delivery is making certain that the baby is ready to be delivered. In general, cesarean deliveries are not scheduled before the 39th week of pregnancy. An amniocentesis may be recommended to determine if the baby's lungs are fully developed, especially if cesarean is planned before 39 weeks of pregnancy.
Most women will meet with an anesthesiologist before planned surgery to discuss the various types of anesthesia available and the risks and benefits of each. Instructions about how to prepare for surgery will also be given, including the need to avoid all food and drinks for 10 to 12 hours before the surgery.
Advantages of planned cesarean — The advantages of a planned cesarean delivery include: It allows parents to know exactly when the baby will be born, which makes issues related to work, childcare, and help at home easier to address. It avoids some of the possible complications and risks to the baby. It avoids the possibility of postterm pregnancy, in which the baby is born two or more weeks after its due date. It helps ensure that a pregnant woman's obstetrician will be available for the delivery. It may offer a more controlled and relaxed atmosphere, with fewer unknowns such as how long labor and delivery will last. It may minimize injury to the pelvic muscles and tissues and the anal sphincters. These injuries sometimes occur during vaginal delivery, which may increase the risk of urinary or anal incontinence.
The benefits of planned cesarean delivery must be weighed against the risks. Cesarean delivery is a major surgery, and has associated risks.
Risks — Because cesarean delivery involves major surgery and anesthesia, there are some disadvantages compared to vaginal delivery. Cesarean delivery is associated with a higher rate of injury to abdominal organs (bladder, bowel, blood vessels), infections (wound, uterus, urinary tract), and thromboembolic (blood clotting) complications than vaginal delivery. Cesarean surgery can interfere with mother-infant interaction in the delivery room. Recovery takes longer than with vaginal delivery. Cesarean delivery is associated with a higher risk that the placenta will attach to the uterus abnormally in subsequent pregnancies, which can lead to serious complications. Cutting the uterus to deliver the baby weakens the uterus, increasing the risk of uterine rupture in future pregnancy. This risk is small and depends upon the type of uterine incision.
Infant risks — There are few risk of cesarean delivery for the infant. One risk is birth trauma, which occurs in 0.4 percent of cesarean deliveries. Temporary respiratory problems are more common after cesarean birth because the baby is not squeezed through the mother's birth canal. This reduces the reabsorption of fluid in the infant's lungs.
Potential complications — The most common complications related to cesarean delivery include infection, hemorrhage (excessive bleeding), injury to pelvic organs, and blood clots. Infection — The risk of postoperative uterine infection (endometritis) varies according to several factors, such as whether labor had started and whether the water was broken. Endometritis is treated with antibiotics.
Wound infection, if it occurs, usually develops four to seven days after surgery, but sometimes appears during the first day or two. In addition to antibiotics, wound infections are sometimes treated by opening the wound to allow drainage, cleansing with fluids, and removing infected tissue if needed. Hemorrhage — One to two percent of all women having cesarean deliveries require a blood transfusion because of hemorrhage (excessive bleeding). Hemorrhage usually responds to medications that cause the uterus to contract. Sometimes surgery, such as curettage (scraping the uterine cavity) is needed. In rare cases, when all other measures fail to stop bleeding, a hysterectomy (surgical removal of the uterus) may be required. Injury to pelvic organs — Injuries to the bladder or intestinal tract occur in approximately one percent of cesarean deliveries. Blood clots — Women are at increased risk of developing blood clots in the legs (deep vein thrombosis or DVT) or the lungs (pulmonary embolus) during pregnancy and the postpartum period. This risk is further increased after cesarean delivery. The risk can be reduced by using a device that gently squeezes the legs during and after surgery, called an intermittent compression device. Women at high risk of DVT may be given an anticoagulant (blood thinning) medication to reduce the risk of blood clots.
MATERNAL REQUEST CESAREAN DELIVERY — The concept of requesting a cesarean delivery is relatively recent. In the United States and most Western countries, pregnant women have the right to make choices regarding treatment, including how they will deliver their child.
A woman who wants to request a cesarean delivery should discuss this decision with her healthcare provider. He or she can provide information about each method of delivery and can help to relieve common fears about pain, the expected process of labor, as well as the woman's right to determine how she will deliver. The woman should also discuss the risks and benefits of maternal request cesarean delivery; in general, the risks are the same as those of a planned cesarean delivery
The woman should also discuss the possible need for a cesearean delivery with future pregnancies "Regardless of a woman's decision, it is possible to reconsider the decision at any time based upon a change in circumstances.
EMERGENCY CESAREAN DELIVERY — In some cases, cesarean delivery is performed as an emergency surgery, after attempting a vaginal delivery. Time may be of the essence, depending upon the situation. Cesarean deliveries performed due to concerns about the mother's or infant's health are started as quickly as possible.
In contrast, if a cesarean is performed because labor has not progressed normally or for other, less serious concerns about the baby's wellbeing, the surgery is usually begun within 30 to 60 minutes.
If an epidural was placed before the attempted vaginal delivery, it can be used to administer anesthesia for the cesarean delivery (a larger dose is necessary for cesarean delivery versus vaginal delivery). Otherwise, spinal anesthesia (or rarely general anesthesia) is given. PROCEDURE — After being admitted to the hospital, a woman may be given an oral dose of an antacid to reduce the acidity of the stomach contents. Another medication may be given to reduce the secretions in the mouth and nose. An intravenous line will be placed into the hand or arm, and an electrolyte solution will be infused. Monitors will be placed to keep track of blood pressure, heart rate, and blood oxygen levels.
Anesthesia — The woman is usually accompanied to an operating room before anesthesia is administered. A spouse or partner can usually stay with the woman in the operating room.
There are two types of anesthesia used during cesarean delivery: regional and less commonly, general. For a planned cesarean delivery, regional anesthesia is usually performed. Meeting with the anesthesiologist allows the woman to ask specific questions about anesthesia, and allows the anesthesiologist to identify any medical problems that might affect the type of anesthesia that is recommended. With epidural anesthesia, the anesthetic is injected into the epidural space surrounding the fluid-filled sac (the dura) around the spine. This numbs the abdomen and legs. With spinal anesthesia, the anesthetic is injected into the subarachnoid space in the lower back. The space contains the cerebrospinal fluid, so the anesthetic causes complete numbness, although the person is still awake. General anesthesia induces unconsciousness. This means that the mother will not be awake or aware during the procedure. After the anesthesia is given, the woman will fall asleep within 10 to 20 seconds and a tube will be placed in the throat to assist with breathing. General anesthesia carries a greater risk of complications because the endotracheal (breathing) tube can cause a severe change in blood pressure and because drugs given to the mother affect the infant.
Regional anesthesia is generally preferred because it allows the mother to remain awake during the procedure, enjoy support from staff and a family member, experience the birth, and have immediate contact with the infant. It is usually safer than general anesthesia. Many practitioners prefer spinal or combined spinal epidural over epidural techniques because of more rapid onset and better blockage of pain. The effect of regional anesthesia begins within a minute or so.
After the anesthesia is given, a catheter is placed in the bladder to allow urine to drain out during the surgery and reduce the chance of injury to the bladder. The catheter is usually removed within 24 hours after the procedure.
Skin incision — There are two basic types of incision: horizontal (transverse or "bikini line") and vertical (midline). Most women have a transverse skin incision, which is made 1 to 2 inches above the pubic hair line. The advantages of this type of incision include less pain, more rapid healing, and a lower chance that the wound will separate during healing.
Less commonly, the woman will have a vertical ("up and down") skin incision in the midline of the abdomen. The advantages of this type of incision include rapid access to the uterus (eg, if the baby is in distress or if the woman is bleeding excessively).
Uterine incision — The uterine incision can also be either transverse or vertical. The type of incision depends upon several factors, including the position and size of the fetus, the location of the placenta, and the presence of fibroids. The main consideration is that the incision must be large enough to allow delivery of the fetus without causing trauma.
The most common uterine incision is transverse. However, a vertical incision may be required if the baby is breech or sideways, if the placenta is in the lower front of the uterus, or if there are other abnormalities of the uterus.
After opening the uterus, the baby is usually removed within a minute or two. After the baby is delivered, the umbilical cord is clamped and cut and the placenta is removed. The abdominal skin is closed with either metal staples or reabsorbable sutures; staples are usually removed within 3 to 7 days while reabsorbable sutures are absorbed by the body and do not need to be removed. After the mother and baby are stable, she or her partner may hold the baby.
POSTOPERATIVE CARE — After surgery is completed, the woman will be monitored in a recovery area. Pain medication is given, initially through the IV line, and later with oral medications.
When the effects of anesthesia have worn off, generally within one to three hours after surgery, the woman is transferred to a postpartum room and encouraged to move around and begin to drink fluids and eat food.
Breastfeeding can usually begin anytime after the birth. A pediatrician will examine the baby within the first 24 hours of the delivery. Most women are able to go home within three to four days after delivery.
The abdominal incision will heal over the next few weeks. During this time, there may be mild cramping, light bleeding or vaginal discharge, incisional pain, and numbness in the skin around the incision site. For up to 6 weeks after the birth, nothing should be placed in the vagina (eg, tampons, douches). Heavy lifting and strenuous activity should be avoided during the first one to two weeks. Most women will feel well by six weeks postpartum, but numbness around the incision and occasional aches and pains can last for several months.
After going home, the woman should notify her healthcare provider if she develops a fever (temperature greater than 100.4º F [38º C]), if pain or bleeding worsens, or there are other concerns.
FUTURE DELIVERIES — Previously, obstetricians recommended that all women who had a cesarean delivery have the same for all future deliveries. However, this is no longer the case. Most women in the United States who have had one low transverse cesarean delivery choose to have a repeat cesarean delivery, although these women could try to have a vaginal delivery with the next pregnancy. Between 60 and 80 percent of women who try to deliver vaginally after a c-section are successful in delivering vaginally. However, women who have a vaginal birth after cesarean (VBAC) have a 1 percent chance that the uterus will rupture during delivery, which could affect the baby's health

BREAS PUMPS




INTRODUCTION — A breast pump is a device that allows a woman to express breast milk from the breasts when it is not possible to breastfeed her infant directly. Many women choose to use a breast pump so that they can continue to provide breast milk while working or if their infant is hospitalized. However, it is not necessary for all women who breastfeed to purchase or use a breast pump.
This topic review discusses the use of breast pumps and breast milk storage and preparation .

CHOOSING A PUMP — There are a wide variety and quality of breast pumps available, each of which varies in cost, quality, and efficiency; the optimal pump depends upon the woman's needs and how frequently the pump will be used. No one pump is best for every woman. In most situations, the purchase of a pump should be delayed until after the infant is born; this will allow the woman to determine her and her infant's individual needs.
Some of the most common reasons women use a breast pump include the following: To provide breast milk after returning to work To provide breast milk because the woman is unable to nurse her infant To provide breast milk when the mother needs to go out for a few hours
Multi-user (hospital grade) pump — A multi-user (hospital grade) double electric breast pump is recommended for women with a premature or ill infant and women who cannot nurse their infant. This is the most efficient, easiest, and fastest type of pump, and is the most effective way to maintain an adequate milk supply for an infant's full nutritional needs. The pump should be used within the first two weeks after the infant is born.
Emptying both breasts with a multi-user double breast pump generally takes about 10 to 15 minutes after let-down has occurred. A multi-user pump can be safely used by more than one woman in a hospital and may be rented for home use. Multi-user pumps are large, heavy, and are not intended to be portable. Some commercial health insurance plans cover the cost of purchasing or renting a breast pump.
Single-user (personal) pump — Single-user (personal) electric breast pumps are made for one woman to use several times per day. They are not suited to maintain a woman's milk supply (without intermittent breastfeeding) long term. The life expectancy of single-user pumps is generally about one year, depending upon how frequently the pump is used. Emptying both breasts with a single-user double breast pump generally takes about 10 to 15 minutes after let-down has occurred.
Most of the high quality single-user pumps are self-contained in a carrying case that includes the motor, supplies, and in some cases, a cooler for storing milk. The pump and related equipment are small and light enough to carry on a daily basis and can pump one or both breasts. These pumps work well for the working mother or when traveling. These pumps are intended for use by only one woman; sharing or re-selling of a personal pump is not recommended. Quality single-user pumps are available from Ameda Medela The cost of this type of pump in the United States is approximately $200.
Single-sided pump — If a woman wants to pump occasionally so that she can leave her baby with a caregiver for a few hours, a single-sided breast pump may be adequate. Single pumps are powered by hand, batteries, or electricity. Single breast pumps are not recommended for women who need to maintain their milk supply while working or for a premature infant, but are adequate for occasional use. Pumping both breasts with a single-sided pump takes about 20 to 30 minutes.
HOW TO PUMP — There are a wide variety of breast pumps, each of which has specific instructions for use. The following are general recommendations for use of a breast pump. Wash the hands with soap and water before pumping. It is not necessary to wash the breasts or nipples . Ensure that the pump pieces and milk collection containers are clean. Washing with warm soapy water is sufficient; it is not necessary to sterilize the pump or bottles. Do not wash the pump tubing because it cannot be dried easily. If moisture or milk is noted in the tubing, contact the manufacturer. It may be necessary to purchase new tubing. Most women prefer to sit while pumping. For electric pumps, set the pump's suction strength to a comfortable level. Pumping should not hurt, even for women with sore or painful nipples. The pump's cycling speed (the number of suction cycles per minute) can be set based on personal preference; some women start with a rapid cycle speed then slow the speed after their milk lets down . Be sure that the flanges (the cone-shaped pieces that fit over the breast and nipples) are the appropriate size. When pumping, the nipples should not rub against the tunnels of the flanges. It may be necessary to purchase larger flanges to pump comfortably and to stimulate the breasts correctly. Be sure to purchase pump parts that are the same brand as that of the pump. Parts should not be interchanged from different manufacturers.
Let-down — Let-down is the term used to describe what happens in the breasts when milk is released from the milk glands to the lactiferous sinuses . Let-down is controlled by two hormones, oxytocin and prolactin. Let-down usually occurs within the first minute or two of nursing or pumping. Some women feel a sense of heaviness or tingling in the breasts during let-down while other women cannot feel let-down at all.
Some women have difficulty with let-down while pumping. In this situation, only drops of milk are seen rather than streams of milk flowing from the nipples. Tips to promote let-down include: Gently massage the breasts before pumping Apply a warm wet cloth to the breasts before pumping Pump in a quiet, darkened room to avoid distractions Look at a picture of the baby or smell the baby's blanket
Pumping at work — Women who work and want to provide breast milk usually need to pump two to three times over eight hours, usually for 10 to 15 minutes with a double electric pump. It can be challenging to find the time and space to pump, especially for women who do not have a private office.
Women should discuss their need for a private space with their employer prior to returning to work. While a bathroom is one option, this is not ideal for pumping. It may be helpful to speak with co-workers who have returned to work and pumped to determine if a private space is available. Some employers offer a "pump room" or other private area.
The United States Center for Disease Control and Prevention has published a number of articles that address the need for support of breastfeeding women who work, citing the health as well as economic benefits of breastfeeding.
Pumping for a premature or ill infant — Women who are pumping for a premature or ill infant are often separated from their child because the child is hospitalized. The benefits of breast milk for premature infants include improved gastrointestinal function and protection from common gastrointestinal and respiratory infections. To maintain a supply of milk when it is not possible to breastfeed, most women need to pump approximately eight to 10 times per day. This usually involves pumping every two to three hours, with one extended period of about six hours (often at night). Women who get up to use the bathroom or begin to feel breast fullness are encouraged to pump at that time as needed.
If a woman is not consistently pumping eight to 10 times in 24 hours, especially during the first two to three weeks of the infant's life, she may not establish an adequate milk supply. Pumping frequently during this time increases the chance that the woman will be able to provide a sufficient amount of milk for the infant's needs over time. By day 10 after delivery, most women who are pumping eight to 10 times per day should be producing approximately 750 to 800 mL (about 25 ounces or 3 cups) of milk per day. However, milk volume varies and can range from 450 to 1200 mL (about 2 to 5 cups) per day.
Women who are pumping less than 450 mL (15 ounces) per day by the 10th day should discuss ways to improve their milk supply with a healthcare provider or lactation consultant (see "Finding a lactation consultant" below). After the initial two to three weeks, some women are able to decrease their pumping to six to eight times per day without jeopardizing the milk supply.
STORING PUMPED MILK — Storage recommendations for breast milk are based upon a small number of studies that have examined the safety and nutritional value of breast milk that is stored under a variety of conditions. These recommendations apply to breast milk intended for full term healthy infants. Women with premature infants should discuss breastmilk storage recommendations with their healthcare provider.
Breast milk that is pumped may be safely stored in the refrigerator or freezer. It can even be left at room temperature (approximately 77º F or 25º C) for up to four hours . This is in contrast to infant formula prepared from powder, which should not be left at room temperature after it is prepared.
Refrigerator storage — Freshly pumped breast milk can be safely stored in a standard refrigerator that maintains the temperature at 32 to 29º F (0 to 4º C) for up to eight days . The coldest part of the refrigerator is preferred, generally towards the back and away from the door. Milk can be stored in an insulated cooler with freezer packs (kept at approximately 60º F or 15º C) for up to 24 hours.
Milk should be stored in a sealed, clean, glass or rigid plastic bottle, or polyethylene bag designed for storing breast milk. Milk should be stored in small amounts (one to four ounces) and labeled with the date it was pumped. Milk from different days or pumping sessions may be combined; the milk should be cooled in the refrigerator before it is combined. The label should indicate the date the oldest milk was pumped. The oldest milk should be used first.
Freezer storage — Freshly pumped or refrigerated breast milk can be stored in a freezer that maintains the temperature at 0 to 6º F (-14 to 18º C) for three to six months. The freezer in a mini-refrigerator does not adequately maintain this temperature range and is not recommended. Pumped milk can be stored in a deep freezer chest (0º F or -18º C or less) for six to 12 months. The coldest part of the freezer is best, generally towards the back and away from the door.
Thawed breast milk can be safely stored in a standard refrigerator for up to 24 hours. Milk that was frozen and then thawed should not be refrozen.
Before freezing, milk should be placed in a sealed, clean, glass or rigid plastic bottle, or polyethylene bag designed for storing breast milk. Milk should be stored in small amounts (one to four ounces) and labeled with the date it was pumped. Milk from different days or pumping sessions may be combined; the milk should be cooled in the refrigerator before it is combined. Milk that is warm or refrigerated should not be added to frozen milk. The milk should be labeled with the date the oldest milk was pumped. The oldest milk should be used first.
If milk smells or tastes spoiled — Breast milk that tastes or smells spoiled should not be given to an infant. Some women's pumped milk tastes and smells spoiled (or soapy, in some cases) within hours to days after it is pumped, even if it is stored at an appropriate temperature. A possible cause of this is a higher than normal level of an enzyme, lipase, in the breast milk. Lipase has benefits, although high levels of lipase break down the fat in breast milk, causing it to quickly taste spoiled. It is not known why some women's milk contains a high level of lipase while others do not.
If a woman notices that her milk smells or tastes spoiled quickly, the breast milk may be heated immediately after it is pumped to inactivate the lipase. Milk should be heated to 180º F (32º C) , but should not be boiled. The milk should then be quickly cooled in a refrigerator or freezer. It is not possible to reverse the enzyme's activity in breast milk after it has been stored, thus milk that smells or tastes bad should be discarded.
Heating milk destroys some of its beneficial qualities; mothers of sick or premature infants should discuss the best way to store milk with their healthcare provider.
HEATING PUMPED MILK — Pumped breast milk that is stored in the refrigerator or freezer should be reheated prior to feeding the infant. Breast milk may be heated in a variety of ways. However, it should not be reheated or defrosted in a microwave because microwaves can heat milk unevenly, potentially burning an infant's mouth. In addition, microwave energy destroys some of the beneficial properties of breast milk .
To safely heat refrigerated or frozen milk, a sealed container of milk can be placed in a bowl or cup of warm water until the milk reaches the desired temperature. Bottle-warming devices are also available for purchase; these should be used with care as they can quickly overheat the milk. Do not leave a bottle warmer unattended.
After warming the milk, the temperature should be tested immediately before it is given to an infant; the milk should feel lukewarm or room temperature, but never hot. Milk should be gently swirled to redistribute the cream that often rises to the top during refrigeration.
There are insufficient data to know if it is safe to refrigerate and then rewarm a partially finished bottle of breast milk. Although freshly pumped breast milk has antibacterial properties, milk stored in a refrigerator for more than a day or two begins to lose this property . Milk that smells or tastes bad should not be given to an infant .
HOW MUCH MILK SHOULD I OFFER? — Many women who exclusively pump or pump while at work wonder how much breast milk their infant will need at each feeding.
The volume of breast milk needed increases with the age of a healthy infant who is exclusively breastfed from 23 to 24 ounces at one month of age to 24 to 30 ounces at six months of age. After six months, most infants begin to consume other foods, and less milk may be needed .
One way to determine how much an infant will need per feeding is to divide the infant's average intake (eg, 25 ounces) by the number of feedings per day . For example, an infant who nurses eight times per day would need approximately 3 ounces per feeding (25 ounces divided by 8 feedings = 3 ounces). Thus, for this infant, it would be reasonable to offer 3 ounces of milk per feeding, with the understanding that some infants will consume less while others will want more.
Feeding breast milk with a bottle — Babies feed very differently from a bottle compared to from the breast. Milk flow from a bottle is fast and the baby usually eats very quickly, sometimes by gulping. Many mothers feel that their infant drinks more milk when he or she is fed with a bottle than when nursed at the breast. It is common to worry that efforts to pump enough milk will be inadequate to keep up with this volume.
Babies have little control over milk flow from a bottle while they have full control over milk flow from the breast. To minimize this problem, it may help to pace the baby while bottle feeding by taking frequent breaks. Slow flow bottle nipples are available and may help to minimize the differences in flow between bottle and breast feeding. A feeding should take 10 to 15 minutes or more, just like at the breast.

Monday, July 13, 2009

Weight Loss Treatments





INTRODUCTION — Obesity is a major international problem and Americans are among the heaviest people in the world. For instance, the percentage of obese people in the United States has risen steadily from 14 percent in the 1976 to 1980 survey to 33.5 percent in the 1999 to 2000 survey .
This topic review discusses how to get started with a weight loss plan, including behavioral plans, diet therapy, and weight loss medications. Weight loss surgery is discussed in a separate topic review.
CONSEQUENCES OF OBESITY — Obesity is associated with many medical problems, most of which improve with weight loss . Both men and women with obesity are at increased risk for the following: Reduced life expectancy Diabetes mellitus Gallstones Hypertension (high blood pressure) Osteoarthritis Coronary heart disease Abnormal blood lipids Stroke Sleep apnea Cancer (colon and prostate cancer in men; uterine and gallbladder cancer in women)
Many people find that they initially lose weight by dieting, although they quickly regain the weight after the diet ends. Because long-term weight reduction is so difficult, it is important to have as much information and support as possible before starting. People who are ready to lose weight and who believe that their body weight can be controlled long-term are usually the most successful.
STARTING A WEIGHT LOSS PROGRAM — Before beginning a weight loss program, you should speak with a healthcare provider so that he/she can help to choose the appropriate treatment, monitor your progress, and provide advice and support along the way.
Determining the severity of the weight problem — In order to know what treatment (or combination of treatments) will work best, a healthcare provider should determine your degree of obesity and distribution of body fat. This can be done by measuring your body mass index (BMI) and waist circumference (measurement). The BMI is calculated from a person's height and weight as follows:
BMI = body weight (in kilograms) / height (in meters) squared. This can also be determined with a calculator . A BMI between 25 and 30 kg/m2 is considered overweight. A BMI greater than 30 kg/m2 is considered to be obese.
A waist circumference greater than 35 inches (88 cm) in women and 40 inches (102 cm) in men indicates that there is an excessive amount of fat in the abdominal area.
Determining the risk for heart disease — The healthcare provider also needs to consider your risk for heart disease before choosing a treatment. For instance: A person with a BMI of 20 to 25 kg/m2 has little or no increased risk for heart disease from obesity unless they have excessive fat in the abdominal area or have gained more than 22 pounds since age 18. A person with a BMI of 25 to 30 kg/m2 has a low risk A person with a BMI of 30 to 35 kg/m2 has a moderate risk A person with a BMI of 35 kg/m2 and above has a high risk
Regardless of a person's BMI, health risks increase if a person: Has excess abdominal fat Has high blood pressure Has high levels of cholesterol in the blood Has heart disease Has a strong family history of diabetes Is male Was obese before age 40
People with the highest risk of heart disease should use the most aggressive weight loss program.
Types of treatment — Depending upon a person's risk factors, BMI, waist circumference, and personal preferences, a healthcare provider will suggest a combination of behavior modification, exercise, dieting, and, in some cases, medications. Surgery is reserved for people with severe obesity who have not responded to other treatments.
SETTING WEIGHT LOSS GOALS — It is important to set a realistic goal for weight loss. The first goal should be to prevent further weight gain and maintain the current weight (within 5 percent). The healthcare provider can help to identify a realistic weight-loss goal. Many people have a "dream" weight that is difficult or impossible to achieve.
A realistic goal — A person at high risk for developing diabetes mellitus who loses 5 percent of their body weight and maintains this weight will reduce their risk for diabetes by about 50 percent. This is a success. Losing more than 15 percent of initial body weight and maintaining this loss is an extremely good result, even if the person never reaches his or her "dream" or "ideal" weight.
BEHAVIOR CHANGES — Behavior change (modification) programs are usually run by psychologists or other trained behavioral professionals. The goals of behavior modification are to help people change their eating habits, increase physical activity, and become more conscious of both of these activities, thereby helping to make healthier choices.
This type of treatment can be broken down into three components: The triggers that make a person want to eat The behavior of eating The consequences of eating
Triggers to eat — Determining what triggers a person to eat involves identifying the foods that a person eats and the settings in which eating occurs. To determine triggers, keep a record for a few days of everything you eat, the places where you eat, how often you eat, and the emotions you were feeling when you ate.
For some people, the trigger is related to a certain time of the day or night. For others, the trigger is related to a certain place, like sitting at a desk working.
Behavior of eating — This component uses stimulus control to break the chain of events between the trigger for eating and eating itself. There are many ways to provide stimulus control. For instance, a person can: Restrict or limit the places they eat Restrict the number of utensils (eg, only a fork) used for eating Drink a sip of water between each bite Chew the food a defined number of times Get up and stop eating every few minutes.
Consequences of eating — This component involves rewarding good eating behaviors. This is not a reward for weight loss; instead, it is a reward for changing unhealthy behaviors.
Food should never be used as a reward. Some people find money, clothing, or personal care (eg, a hair cut, manicure, or massage) to be effective rewards. The reward should be given immediately after the improved behavior to reinforce the value of the good behavior.
Behavior goals need to be clearly defined, and there must be an agreed-upon timeframe for achieving goals. It is often important to reward small changes along the way to the final goal.
Other factors that contribute to successful weight loss — Behavior modification is more than just changing unhealthy eating habits; it also includes developing an internal and external support system, reducing stress, and learning to be assertive. Establishing a "buddy" system — Having a friend or family member available to provide support and reinforce good behavior changes is very helpful. The support person needs to be sympathetic to the person's goals and can be trained by the program director or the person losing weight. Learning to be assertive — It is important to provide opportunities for role-playing in difficult situations. For instance, people trying to lose weight need to learn how to refuse food offered at parties and social gatherings. One strategy is to use assertiveness training, a technique for learning how to say "no" and continuing to say no when urged to eat. Role playing can be done with a partner or in a group. Develop a support system — Having a support system is helpful when losing weight. This is why many commercial groups are successful. Family support is also essential, since negative attitudes about losing weight can slow or even prevent success. Positive thinking — People often have conversations with themselves in their head; these conversations can be positive or negative. If a person eats a piece of cake that is not on their weight loss program, they may respond by thinking, "Oh, you stupid idiot, you've blown your diet!" and, as a result they may eat more cake. A positive thought for the same event could be, "Well, I have eaten cake when it was not on my plan and now I should do something to get back on track." This positive approach is much more likely to be successful than negative, self-deprecatory thoughts. Stress reduction — Although stress is a part of everyday life, it can trigger uncontrolled eating in some people. It is important to find a way to get through these difficult times without eating or by eating low-calorie food, like raw vegetables. It may be helpful to identify a relaxing place that allows a temporary escape from stress. With deep breaths and closed eyes, the person can imagine this relaxing place for a few minutes. Self-help programs — Self-help programs like Weight Watchers, Overeaters Anonymous, and Take Off Pounds Sensibly (TOPS), work for some people. However, these programs have a high drop-out rate. Psychotherapy — Behavioral treatments, including individual psychoanalysis, family or couples training, and self-help groups can help with weight loss efforts.
DIET THERAPY — A calorie is a unit of energy found in food. The body needs calories to function. If a person takes in more calories than they use, approximately 75 percent of the extra calories are stored as fat and the remaining 25 percent as lean tissue. The goal of any diet is to burn up more calories than are taken in, which results in weight loss.
The rate at which a person loses weight can vary: the heavier the person, the quicker the weight loss on any given diet. Weight loss also can be influenced by age and sex. Men lose more weight than women of similar height and weight when dieting because they have more lean body mass and, therefore, use more energy. Older people have a slower metabolism than young people, and thus lose weight at a slower rate.
Conventional diets — Conventional weight reduction diets provide at least 800 calories a day, but less than what the body requires. These diets fall into four groups: Balanced low-calorie diets / portion-controlled diets Low-carbohydrate diets Low-fat diets Fad diets (these are diets that involve unusual food combinations or eating certain foods in a particular order)
Diets in the range of 1,200 to 1,500 calories are suitable for most people; men should eat a diet with close to 1,500 calories per day while women should eat a diet with close to 1,200 calories per day.
Balanced low-calorie diets — When starting a diet, it is important to determine an appropriate calorie level, as well as a combination of foods, to meet an individual weight loss goal. It is best to choose foods that contain adequate protein, carbohydrates, essential fatty acids, and vitamins. Alcohol, sugar-containing beverages, and most highly concentrated sweets (candy, cakes, cookies) should be eliminated from weight-loss diets since they rarely contain adequate amounts of nutrients other than calories.
Portion-controlled diets — One simple way to diet is to buy packaged foods, like frozen low-calorie meals. This can be supplemented with formula diets using powdered or liquid drinks. A typical meal plan for one day may include a formula diet or breakfast bar for breakfast, a formula diet or a frozen meal for lunch, and a frozen calorie-controlled entree for dinner. This would give the person 1,000 to 1,500 calories per day.
Low-fat diets — High fat diets, especially diets that are high in saturated and trans fat foods, increase the risk of obesity, heart disease, and certain forms of cancer, among other adverse effects. Almost all dietary guidelines recommend limiting fat intake to 30 percent of total calories or less.
A low-fat diet can be implemented in two ways. First, a dietitian can provide a specific menu plans that emphasizes the use of reduced fat foods. As one guideline, if a food "melts" in the mouth, it probably has fat in it. Second, a person can learn how to count fat grams. Many experts recommend keeping calories from fat to below 30 percent of total calories. For a 1500 calorie diet, this would mean about 45 g or less of fat, which can be counted using the nutrition information labels on food packages.
Low-carbohydrate diets — Carbohydrates are found in fruits, vegetables and grains (including breads, rice, pasta, and cereal), alcoholic beverages, and in dairy products. Meat and fish do not contain carbohydrates. Low-carbohydrate diets (eg. Atkins diet, South Beach Diet) have become extremely popular as a way to lose weight quickly. With a low-carbohydrate diet, between zero and 60 grams of carbohydrates are eaten per day (as compared to a standard adult diet which contains approximately 200 to 300 grams of carbohydrates).
Very low carbohydrate diets may be associated with more frequent side effects than low-fat diets. In one clinical trial, constipation, headache, bad breath, muscle cramps, diarrhea, general weakness, and rash occurred significantly more frequently in the low-carbohydrate compared to the low-fat diet group .
Diet comparison — One trial compared four different diets: (very low-carbohydrate [Atkins], macronutrient balance controlling glycemic load [Zone], calorie restriction [Weight Watchers], and very low-fat [Ornish]) . Average weight loss at one year for those who completed the study was approximately 4 to 7 kg (8.8 to 15.4 lbs), and was not different between the four diets.
Higher dropout rates were noted after one year with the very low-carbohydrate and very low-fat diets compared to the more moderate diets (48 percent for Atkins, 50 percent for Ornish, and 35 percent for Weight Watchers and Zone).
Fad diets — Fad diets often promise quick weight loss (more than 1 to 2 pounds per week), claim that it's unnecessary to exercise or give up favorite foods, limit food choices, or require the person to pay large amounts of money for seminars or pills. They generally lack any scientific evidence that they are safe and effective, but instead rely on "before" and "after" photos.
Diets that sound too good to be true usually are; these plans are a waste of time and money and are not recommended. A healthcare provider or nutritionist can help determine a safe and effective way to lose weight and keep it off.
WEIGHT LOSS MEDICATIONS — Drug therapy may be helpful for some obese people when used in combination with diet, exercise, and behavior modification. People who are overweight who want to start a weight loss medication must carefully evaluate the risks and benefits with a healthcare provider. There are situations in which drug therapy is appropriate; as an example: People who are obese (BMI > 30 kg/m2) (show calculator) Overweight people (BMI between 27 and 30 kg/m2) who have other medical problems such as diabetes, high cholesterol, or high blood pressure, which further increase the risk of heart disease.
Goals of drug therapy — The goals of any weight loss program, including drug therapy, must be realistic: It is unrealistic to expect body weight to return to "normal". Weight loss should be greater than 2 kg (approximately 5 pounds) during the first month of drug therapy in order for it to be continued. Weight loss of 10 to 15 percent is considered a good response; weight loss exceeding 15 percent is considered an excellent response.
There are two drugs available for the long-term treatment of obesity; a third drug is in the final stages of becoming approved.
Sibutramine — Sibutramine (Meridia®, Reductil®) is an appetite suppressant that is effective for many people. The recommended starting dose is 5 to 10 mg per day; doses above 15 mg per day are not recommended. In people who complete one year of therapy, the average weight loss is 10 percent of the initial body weight (5 percent more than those who took a placebo treatment).
Side effects include insomnia, dry mouth, and constipation. Increases in blood pressure can occur. Therefore, the blood pressure is usually monitored during treatment. Sibutramine is not recommended for people with a history of heart disease or stroke. There is no evidence that sibutramine causes cardiac valve abnormalities or pulmonary hypertension (like dexfenfluramine and fenfluramine (Phen/Fen)).
Orlistat — Orlistat (Xenical® 120 mg capsules) is a medication that reduces fat absorption and helps some obese people to lose weight. A lower dose version is now available without a prescription (Alli® 60 mg capsules) in many countries, including the United States. The medication is recommended three times per day, taken with a meal; a dose may be skipped if a meal is skipped or if the meal contains no fat.
After one year of treatment with orlistat, the average weight loss is approximately 8 to 10 percent of initial body weight (4 percent more than those who took a placebo). Cholesterol levels often improve and blood pressure sometimes fall. In people with diabetes, orlistat may help control blood glucose levels.
Side effects occur in 15 to 10 percent of people, and may include stomach cramps, gas, diarrhea, leakage of stool, or oily stools. These problems are more likely when orlistat is taken with a high fat meal (if more than 30 percent of calories in the meal are from fat). Side effects are usually mild and subside as people learn how to avoid these problems by avoiding high fat diets and sticking to the recommended intake of no more than 30 percent fat.
Rimonabant — Rimonabant (Accomplia®) is a cannabinoid receptor antagonist. It was developed based upon the idea that people who smoke marijuana (cannabis) often develop extreme hunger. Rimonabant blocks cannabis receptors in the brain, which reduces appetite. In one clinical study, it produced 8 to 9 percent weight loss after one year (5 percent better than placebo). Blood pressure, HDL-cholesterol, triglycerides, and metabolic syndrome typically improve during treatment.
Side effects of rimonabant can include anxiety and depression. It is available in Europe but is not yet available in the United States.
Diet supplements — Over-the-counter dietary supplements are widely used by people who are trying to lose weight, although the safety and efficacy of these supplements are unproven. Examples of dietary supplements include ephedra (described below, no longer available), green tea, chromium, chitosan, and wheat dextrin. Ephedra, a compound related to ephedrine, is no longer available in the United States due to safety concerns. Many over-the-counter diet pills previously contained ephedra. Although some studies have shown that ephedra sometimes helps with weight loss, there can be serious side effects (psychiatric symptoms, palpitations, and gastrointestinal symptoms), including death. Chitosan and wheat dextrin are ineffective for weight loss, and their use is not recommended. There are not enough data regarding the safety and efficacy of chromium, ginseng, glucomannan, green tea, hydroxycitric acid, L carnitine, psyllium, pyruvate supplements, St. Johns wort, and conjugated linoleic acid. Until more information is available, these supplements are not recommended for the purpose of weight loss. Two compounded dietary supplements imported from Brazil, Emagrace Sim (also known as the Brazilian diet pill) and Herbathin dietary supplement, have been shown to contain prescription drugs. The Food and Drug Administration has warned of the potential danger of this supplement. Hoodia gordonii, a dietary supplement derived from a desert plant in South Africa, is marketed and sold as an appetite suppressant. However, it has not been proven safe or effective.

SUNBURN

















INTRODUCTION — Sunburn results when skin is burned by ultraviolet (UV) radiation, most often after excessive sun exposure. It is common, with nearly 32 percent of adults and between 72 and 83 percent of children and adolescents reporting at least one sunburn during the course of a year.
This topic reviews the symptoms, causes, potential complications, and treatment of sunburn. Prevention of sunburn is discussed separately.





SYMPTOMS — Unlike other types of burns, sunburn is not immediately apparent because redness develops between three and five hours after sun exposure. Common symptoms of sunburn include reddened skin that is hot to the touch and skin pain; more severe sunburns cause swelling and blistering.
Redness peaks approximately 12 to 24 hours after sun exposure and fades over 72 hours.
CAUSES/RISK FACTORS — Normally, the body's protective pigment, melanin, protects the skin from becoming sunburned. If the skin is exposed to excessive UV radiation, it becomes burned. The amount of UV radiation required to burn the skin varies according to the amount of melanin in an individual's skin. In general, people with fair skin and light-colored hair have less melanin and are at higher risk of damage from UV exposure compared to people with darker-colored skin.
In addition, people who live in regions that are closest to the equator and areas of high altitude (eg, mountainous areas) are at higher risk for developing sunburn.
The primary source of UV radiation is the sun, which can cause sunburn in some people in less than 15 minutes. Tanning beds are another source of UV radiation.
Certain medications, such as nonsteroidal antiinflammatory drugs (eg, ibuprofen), quinolone and tetracycline antibiotics (eg, Cipro®, tetracycline), furosemide (Lasix®) and hydrochlorothiazide, psoralens and phenothiazines (eg, compazine), make the skin more sensitive to burning. People taking these medications should avoid the sun and use protective measures to avoid sunburn.
DIAGNOSIS — Sunburn is usually diagnosed based upon a person's memory of sun or tanning bed exposure, symptoms of sunburn, and the appearance of a skin reaction on sun-exposed skin.
COMPLICATIONS — Sunburn is associated with premature aging and wrinkling of the skin as well as skin cancer, including malignant melanoma, a serious form of skin cancer. Sun exposure and ultraviolet damage have also been implicated in the development of cataracts. TREATMENT — Treatments for sunburn include measures to relieve skin discomfort. Further sun exposure should be avoided until skin redness and pain resolve. Non-steroidal antiinflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen are useful to relieve pain, especially when taken as soon as pain is noticed; the benefit of NSAIDs decreases after 24 hours.
For mild sunburns, cool compresses, aloe-based lotions, and lotions or sprays with a local anesthetic (numbing medication, eg, Solarcaine®, Dermaplast®) are advertised to provide some short-term relief of discomfort. However, clinical studies have not proven a definite benefit from these products. In addition, these treatments do not reduce the long-term risks of sunburn.

WHEN TO SEEK HELP — If sunburn is severe, call a healthcare provider to determine if treatment should be given at home, in the office, or in an emergency department.
Symptoms of a severe sunburn include severe pain and skin blistering. A person with severe sunburn can also have heat stroke or heat exhaustion, which can cause fever, headache, confusion, nausea, vomiting, visual difficulties, and fainting; this should be treated promptly in an emergency department.

Sunday, July 12, 2009

How to Use Metered dose inhaler (MDI)







What is a metered dose inhaler?
A metered dose inhaler (MDI), also known as an aerosol inhaler or puffer, is a device for delivering medicine directly into the lungs. It consists of a pressurised metal canister containing a solution or suspension of medicine, placed within a plastic case with a mouthpiece. When the canister is pushed down, a valve delivers a measured dose of medicine in a fine mist. This is inhaled into the lungs via the mouthpiece. Using an inhaler delivers your medicine directly into the lungs where it is needed.
Using such an inhaler device can require considerable coordination, but it is important that the correct technique is used. If not, you won't fully inhale the correct dose of your medicine. This not only makes it less effective, but may also result in the medicine ending up in your mouth or throat, where it can cause side effects such as throat irritation.
How to use an MDI
Sit up straight or stand up and lift the chin to open the airways.
Remove the cap from the mouthpiece and shake the inhaler vigorously.
If you haven't used the inhaler for a week or more, or it is the first time you have used the inhaler, spray it into the air first to check that it works.
Take a few deep breaths and then breathe out gently. Immediately place the mouthpiece in your mouth and put your teeth around it (not in front of it and do not bite it), and seal your lips around the mouthpiece, holding it between your lips.
Start to breathe in slowly and deeply through the mouthpiece. As you breathe in, simultaneously press down on the inhaler canister to release the medicine. One press releases one puff of medicine.
Continue to breathe in deeply to ensure the medicine gets into your lungs.
Hold your breath for 10 seconds or as long as you comfortably can, before breathing out slowly.
If you need to take another puff, wait for 30 seconds, shake your inhaler again then repeat steps 4 to 7.
Replace the cap on the mouthpiece.
Other useful advice
MDIs are much more effective and easy to use when used with a space device.
Practice using your inhaler in front of the mirror a few times. If you see mist coming from the top of the inhaler, or from the sides of your mouth, or your nostrils, you are not inhaling the dose correctly.
You can check your inhaler technique with your doctor, practice nurse or pharmacist.
If you can't get to grips with the coordination of an MDI, there are several other types of inhaler on the market (eg Autohalers, Accuhalers, Diskhalers). You may find some of these easier to use, so talk to your doctor, practice nurse or pharmacist for advice about which one may be best for you.
If you have weak hands you may find it easier to hold the inhaler with both hands and push the canister down with both index fingers rather than one. There is also a device available called a Haleraid, to help people use aerosol inhalers. Ask your pharmacist or practice nurse about this.
The propellants used in aerosol inhalers have been gradually replaced by more environmentally friendly CFC-free propellants. The new inhalers may look, feel and taste different but they will supply exactly the same medicine and are just as effective.
It is important to clean your inhaler regularly about once a week, otherwise it may not work properly. Remove the metal canister and mouthpiece cap from the case of the inhaler. Wash the case and cap in warm soapy water. Rinse in warm water then leave to dry. The holes in the valve sticking out of the bottom of the canister can sometimes become blocked - they can be cleaned with a pin.
Avoid spraying the inhaler into your eyes, as this can be harmful.
Always use your medicines as advised by your doctor or pharmacist.
Don't give your medicines to anyone else to use, even if they have the same symptoms as you. They may be harmful to other people.
Always keep medicines out of the reach of children.
If you forget to take a dose of your inhaler, take the dose as soon as you remember, and then go on as before.
STORAGE: all inhaler devices should be stored in a cool, dry place and out of direct sunlight.
Inform your doctor or pharmacist if you accidentally take more than you were supposed to.
Preventers and relievers
Inhalers are usually colour coded. Blue inhalers are 'relievers'. They contain medicine to relax the airways such as salbutamol (eg Ventolin)or terbutaline (eg Bricanyl), and are used to relieve shortness of breath and wheezing. They should work within a few minutes.
If you find your reliever becomes less effective or you need to use it more frequently, talk to your doctor or practice nurse as soon as possible. Your treatment may need to be altered.
Brown/beige/white/red/orange inhalers are 'preventers' (although some generic salbutamol inhalers are white). Preventers contain medicine that reduces inflammation in the airways and prevents asthma attacks. They must be used regularly as directed by your doctor in order to prevent shortness of breath and wheezing.
If you have a preventer inhaler that contains a corticosteroid (eg beclometasone, fluticasone) you should rinse your mouth with water after using it. This helps prevent the oral thrush that can be a side effect of this type of inhaler.
If you are using both preventer and reliever inhalers, it is important that you use the reliever first. This helps open the airway passages and allows the preventer medicine to get down into the lungs more effectively

EXERCISE




INTRODUCTION — Physical activity is any activity that involves major muscle groups, including routine daily activities such as shopping or climbing stairs. Exercise includes any activity done with a goal of improving or maintaining physical fitness.
Physical fitness can be described as the ability to carry out daily tasks with vigor and alertness, without excessive fatigue, and with ample energy to enjoy leisure time pursuits and meet unforeseen emergencies.
Many Americans have little or no physical activity in their daily lives. Approximately 24 percent of adults in the United States do not engage in any leisure time physical activity, while only about 49 percent perform the recommended amount of physical activity (at least 30 minutes of moderate physical activity five or more days per week) .
There are three main types of exercise: Aerobic exercise Resistance training Stretching exercise
This topic review discusses exercise and its benefits for adults. A separate topic discusses exercise recommendations for people with arthritis. Aerobic exercise — Aerobic exercise involves exertion such as walking, running, or swimming, which increases the flow of blood through the heart. Aerobic means "with oxygen" and refers to working at a level where the large muscles get adequate oxygen from the blood to sustain prolonged activity. Spontaneous activity (fidgeting) can burn 100 to 800 calories/day.
Resistance training — Resistance training is exercise designed to increase muscle strength, and includes lifting weights. This kind of exercise is sometimes called anaerobic, meaning "without oxygen." In contrast to aerobic exercise, the muscles do not get enough oxygen to sustain anaerobic exercise for prolonged periods of time. As an example, anaerobic exercise might involve lifting a heavy weight a number of times, after which the involved muscles are deprived of oxygen and are too fatigued to continue that level of exertion.
Stretching exercise — Stretching exercises are movements designed to improve flexibility and prevent injury. Improving flexibility allows joints to move over a wider range of motion. Good range of motion in all joints helps to maintain musculoskeletal function, balance, and agility.
BENEFITS OF EXERCISE — Apart from improving overall physical fitness, exercise has numerous health benefits: The risk of dying is decreased in those who exercise regularly. As an example, one study found that men who engaged in moderately vigorous sports had a 23 percent lower risk of death than men who were less active Exercise also helps to lower the risk of death in men with coronary artery disease . Exercise is an essential component of weight management programs. Exercise burns calories and may help to burn calories even while not exercising. Dieting can lead to loss of muscle, but exercise can help maintain muscle mass while dieting. Exercise improves blood sugar control in people with diabetes and can help prevent or delay the onset of type 2 diabetes. Aerobic exercise helps decrease blood pressure; this effect may be even greater in people with high blood pressure.Exercise often improves the blood fats (lipid profile) by decreasing triglyceride levels and raising HDL (good cholesterol) levels. (See "Patient information: High cholesterol and lipids (hyperlipidemia)"). Most people report a reduction in stress after they exercise. Research has shown that exercise is associated with reduced tension, anxiety, and depression. Weight-bearing exercise helps to prevent osteoporosis and reduces the incidence of fractures. Exercise training can improve circulation and exercise tolerance for people who have angina (chest pain from a reduced blood supply to the heart). After exercise training, a person may be able to exercise longer or at a greater intensitySome evidence suggests that exercise can provide protection against breast and prostate cancer, can delay or prevent dementia, and can decrease the risk of gallstone disease. Exercise can help with quitting smoking.
A summary of benefits is provided here .
TESTING BEFORE AN EXERCISE PROGRAM — Most people do not need any special testing before starting to exercise, but it is best to check with a healthcare provider. People with diabetes or multiple risk factors for heart disease may need an exercise test before starting an exercise program. An exercise test is performed in a doctor's office or hospital, and usually involves walking or running on a treadmill with monitoring leads on the chest.
GETTING STARTED — If you do not normally get much exercise, start by exercising for a few minutes at a low intensity (eg, walking). As physical fitness improves, you can slowly begin to exercise harder, more frequently, or for a longer time, with a goal of getting at least 30 minutes of exercise on five days each week.
Exercise does not need to be continuous to produce health benefits; it can be broken up into three or four ten-minute sessions per day. Moderate intensity exercise should be performed on most days of the week. However, exercising only one or two days per week is better than not exercising at all.
The greatest health benefits are seen in those who change from a sedentary lifestyle to being moderately active .Moderate exercise can be integrated into your daily routine with activities such as brisk walking (at three to four miles per hour), yard work, or dancing.
A simple way to start exercising is to walk. Start by walking a comfortable distance; establish a personal baseline by walking at a speed and for a length of time that is easily tolerated. Doing too much too fast may result in discomfort, disappointment, or disability from muscle pulls and strains. Try to increase your baseline distance by 10 percent each week. Measure out the distance in a neighborhood, walking trail, or shopping mall.
After reaching 45 to 60 minutes per day, you can increase the intensity of exercise by walking a greater distance in the same time. The goal is to develop a habit of regular physical activity at a level that is comfortable.
EXERCISE PROGRAM — An exercise program should include aerobic exercise, resistance training, and stretching.
Warm up — Exercise sessions should begin with a five to ten minute period of warm up. Start with some low level aerobic exercises (walking, stationary cycling, calisthenics) and then do stretches and flexibility movements. The warm-up period allows for a gradual increase in the heart rate and may reduce the risk of injuries.
Workout — It is a good idea to mix up aerobic exercise, strength training, and stretching so as to keep the workout fun and interesting.
Aerobic exercise — Walking is an excellent aerobic activity. Cycling, rowing, stair machine climbing, and other endurance-type activities are also great. Swimming and water aerobics are excellent for people with arthritis. Low impact activities are recommended because they are less likely to result in physical injury. Running on a street is a higher impact activity because of the stresses on the feet and legs as they strike the ground with each step.
The exercises should be enjoyable and simple to carry out to encourage a long-term commitment. It may be best to vary the exercises you do each week (such as swim on three of the days and walk on three of the days) to decrease repetitive strain to your muscles and other tissues.
There is no age specific heart rate recommendation; a specific heart rate is not necessary to achieve health benefits. If you are breathless, fatigued, and sweating, you have worked hard enough. During moderate intensity exercise, you should be able to carry on a conversation.
A minimum of 30 minutes of moderate intensity aerobic exercise (eg, brisk walking) is recommended on five days each week. Alternately, you can perform 20 minutes of vigorous-intensity aerobic exercise (eg, jogging) on three days each week. This recommendation is in addition to routine, light-intensity activities of daily living (eg, cooking, casual walking, shopping, etc) .
Resistance training — Resistance training can be done with weights, machines, or exercise bands. It should be performed at least twice a week with at least 48 hours of rest between sessions. Resistance training is commonly described in terms of "sets" of "repetitions." A repetition is a single completed back and forth motion of a resistance exercise, such as bending and extending the arm at the elbow while holding a weight in the hand. A set is a number of repetitions done without resting.
Most experts recommend at least one set of exercises, including 8 to 12 repetitions, for each of the major muscle groups.
Begin with minimal resistance (light weights, resistive bands, or even a can of food) to allow the muscles and other tissues to adapt. Examples of exercises for the upper body are shown in figure two ).
It is important to use proper technique. If you belong to a health club or gym might ask a trainer to observe technique. Be sure to maintain breathe normally while lifting weights. Do not hold the breath; instead, exhale with exertion. Do not perform resistance training during if you are in pain or have swelling anywhere.
Stretching — Stretching and flexibility exercises should include every major joint (hip, back, shoulder, knee, upper trunk, neck). It is best not to stretch "cold" muscles, so engage in a few minutes of low intensity aerobic exercise first. Movement into a stretch should be slow, and the stretch itself should be held for approximately 10 to 30 seconds. Do not bounce while beginning or performing a stretch.
Stretching exercises .Each exercise should be performed several times. Stretch and yoga classes are also a good way to remain flexible. The stretch should not cause pain, but only mild discomfort.
Cool down — Cool-down exercises should be done for approximately five minutes at the end of an exercise session. Similar to the warm-up period, cool-down may include low level aerobic exercise (such as slow walking), calisthenics, and stretching. This allows the body to clear acid that has built up in the muscles and allows more blood back into the circulation because less is sent to the muscles. This helps to prevent muscle cramps and sudden drops in blood pressure that can cause lightheadedness.
EVALUATING AN EXERCISE PROGRAM — Exercise should fit into the daily schedule, should be enjoyable, and should feel safe. After beginning an exercise program, most people start to notice that they feel healthier.
However, it is common for an exercise program to be disrupted by health problems, changes in job type or hours, personal relationships, and vacations. Getting back on track can be tough, but is an important step in maintaining the benefits of exercise.
If your exercise program does not fit into your daily life, try to find ways to integrate exercise so that it can remain a part of your daily routine. For example, take the stairs instead of the elevator, park in a space that is further from the door, or take a longer route to walk from one place to another.
WHEN TO SEEK HELP — In order to exercise safely, it's important to know the warning signs that could indicate a problem. If any of these problems occur, you should stop the exercise or activity and contact your healthcare provider immediately: Pain or pressure in the chest, arms, throat, jaw or back Nausea or vomiting during or after exercise Palpitations or heart flutters or a sudden burst of a very fast heart rate Inability to catch your breath Lightheadedness, dizziness or feeling faint during exercise (feeling lightheaded after exercise may mean that a longer cool-down period is needed) Feeling very weak or very tired Pains in joints, shins, heels or calf muscles (this is not an emergency, but should be evaluated if it does not resolve)
PRECAUTIONS Remember to drink fluids during and after exercise. Thirst is a good indicator that more fluids are needed. Do not exercise outdoors if the temperature is too hot or too cold. In cooler weather, it is better to wear layers of clothes while exercising outdoors. A layer of clothing can be removed if needed. Wear supportive, well-fitting running or walking shoes. Replace shoes when signs of deterioration develop (eg, cracking, separation of shoe from the sole, imprint of the foot in the insole). The amount of time exercise shoes will last depends upon a number of factors, including how often and where the shoes are worn.