Recent Advances in the Management of IBS

Medivision presents an excerpt from our 60 minute medical education video Recent Advances in the Management of IBS (Irritable Bowel Syndrome), featuring Brenda Toner, PhD. The full length film, along with many other medical education titles, is available on VHS or DVD from health-e-mall.com and describes the application of symptom-based criteria for diagnosis of IBS, the role of dysmotility and visceral hypersensitivity in IBS, patient care and the role of pharamacotherapeutic agents.

Irritable bowel syndrome (IBS), a functional gastrointestinal disorder long considered a diagnosis of exclusion, has chronic symptoms that vary over time and overlap with those of non-IBS disorders. Traditional symptom-based criteria effectively identify IBS patients but are not easily applied in clinical practice, leaving over 40% of patients to experience symptoms up to 5 years before diagnosis.

The myoelectric activity of the colon is composed of background slow waves with superimposed spike potentials. Colonic dysmotility in irritable bowel syndrome manifests as variations in slow-wave frequency and a blunted, late-peaking, postprandial response of spike potentials. Patients who are prone to diarrhea demonstrate this disparity to a greater degree than patients who are prone to constipation.
Small bowel dysmotility manifests in delayed meal transit in patients prone to constipation and in accelerated meal transit in patients prone to diarrhea. In addition, patients exhibit shorter intervals between migratory motor complexes (the predominant interdigestive small bowel motor patterns).
Current theories integrate these widespread motility aberrations and hypothesize a generalized smooth muscle hyperresponsiveness. They describe increased urinary symptoms, including frequency, urgency, nocturia, and hyperresponsiveness to methacholine challenge.

Visceral hypersensitivity (the experience of pain in internal organs at an increased level than what is normally expected) may also play a role in irritable bowel syndrome (IBS). This pain sensitivity is usually studied using some variation of balloon distention in the rectum, and as an overall research trend people who suffer from IBS experience discomfort and pain in the rectal area at lower levels of pressure than individuals who do not suffer from IBS. But the issue is not a simple one; it appears likely that the visceral hypersensitivity seen in some IBS patients is a result of changes in nervous system functioning on both the level of the intestines and the brain. At the level of the gut, it seems as if nerve pathways in the gastrointestinal tract become sensitized to stimulation, resulting in over-reactivity and resulting in pain amplification. Brain imaging studies provide more clues; in individuals who do not have IBS, rectal distension triggers a response in parts of the brain that are associated with modulating pain. In IBS patients, this same rectal stimulation triggers a response in the parts of the brain associated with vigilance and anxiety -- parts of the brain that serve to amplify the sensation of pain.

Certain types of psychotherapy have been shown to be effective in reducing IBS symptoms. Although it is not known precisely why therapy is beneficial, it is thought to be related to the effect of the therapy on the close interconnections between the brain and the intestinal system.

Cardiology Perspectives: Effective Management of Cholesterol

Medivision.com is pleased to present an excerpt from our 2 hour educational video; Cardiology Perspectives: Effective Management of Cholesterol, featuring John Kane, MD; Alan Chait, MD; John LaRose, MD; Tom Bersot, MD; Stephen G. Young, MD; Gustav Schoenfeld, MD and Virgil Brown, MD. The full length video is available on DVD or VHS from health-e-mall.com and discusses the importance of controlling cholesterol in patients with heart disease and other high risk individuals.

High cholesterol is a well-known risk factor in heart disease, the number one killer of both women and men in the United States, with more than a million heart attacks and about a half million deaths annually.
High cholesterol doesn't cause overt symptoms, and many people are unaware of elevated cholesterol levels and how it may influence their cardiac risk. To complicate matters, high cholesterol is not the only predictor of cardiovascular events such as heart attack and stroke; somewhere between 30-50 percent of first heart attacks occur in people with normal cholesterol levels, but it is essential to test and monitor cholesterol levels, especially for anyone with a family history of heart disease. Lowering high cholesterol does seem to lessen the risk for developing heart disease, and reduces the chance of a heart attack or dying of heart problems if you already have them. However, some research has indicated that all-cause mortality (that is, dying from any disease, not just heart disease) actually increases when cholesterol is lowered in those over age 65.

Genetics and lifestyle both combine in individuals to create high levels of cholesterol in the blood. Those who are overweight tend to have increased cholesterol.
Diet is an important component of controlling cholesterol ratios and maintaining heart health. Recent evidence indicates that added sugar and overabundance of flour in the diet are probably greater contributors to heart disease than saturated fat; certain components of full-fat dairy foods may be cardio-protective.
However, a chemically altered type of fat known as trans fatty acids (TFAs) can worsen cholesterol ratios. TFAs are mostly found in animal fats and vegetable oils, and are also created in the hydrogenation process that makes fats more stable, giving them a longer shelf-life.
In addition to diet, LDL cholesterol levels appear to be heavily dependent on genetic factors. Anyone at increased risk of heart disease should have tests for LDL particle size in addition to the basic lipid profile. Best results show low numbers of LDL particles overall.
A different cholesterol problem is present when one shows a tendency towards low HDL cholesterol and high triglycerides. This pattern, sometimes called “Syndrome X,” is associated with insulin resistance. It is frequently influenced by diet and lifestyle, but is also genetically driven and appears to affect at least 30 percent of the population. It carries with it an increased risk of high blood pressure and diabetes as well as heart disease. Dietary and nutritional supplement treatments are often quite effective in treating this pattern, but are a bit different from those for high total and LDL cholesterol levels.

High cholesterol is treated conventionally with lifestyle changes focusing on diet, physical activity and weight management. For patients seen in busy medical practices this approach is frequently difficult to fully implement and utilize. If lifestyle changes are not effective, drug therapy is often recommended. Statin drugs are commonly used to lower cholesterol and protect against heart disease and heart attacks by blocking an enzyme that is necessary for the synthesis of cholesterol in the liver. They can be very effective, and there is growing medical enthusiasm for them because they also seem to provide antioxidant and anti-inflammatory properties. These drugs can reduce plaque formation in coronary arteries by preventing the oxidation of LDL ("bad") cholesterol, and their anti-inflammatory properties may help prevent plaque from rupturing.
Despite their benefits, they do have adverse effects including liver toxicity: physicians need to monitor liver function carefully in patients with liver disease of any kind.

Understanding the Role of Estrogen: What is Menopause?

Medivision presents an excerpt from our 90 minute medical education video Obstetrics and Gynecology: Understanding the Role of Estrogen, featuring Matan Yemini, MD. on the topic of "What is Menopause?". The full length film, along with many other medical education titles, is available on VHS or DVD from health-e-mall.com and covers the following topics: Comprehensive Health Care to the Peri-Menopause, Current Research Trends, Hormone Replacement Therapy and Nursing Perspectives in Menopause Management.

Hormone replacement therapy was recently considered to be a standard treatment for women with hot flashes and other menopause symptoms, and was also thought to have the long-term benefits of preventing heart disease and possibly dementia. However the use of hormone therapy changed abruptly when a large clinical trial found that one type of hormone therapy actually posed more health risks than benefits, particularly when given to older postmenopausal women. As the concern about health hazards attributed to hormone therapy grew doctors became less likely to prescribe it, and it is no longer recommended for s heart disease or memory loss.

However, further review of clinical trials and new evidence show that hormone therapy may still be a good choice for certain women, depending on their risk factors and on whether they take systemic hormone therapy or low-dose vaginal preparations of estrogen. For women who experience menopause naturally, estrogen is typically prescribed along with progesterone or progestin because estrogen alone can stimulate growth of the lining of the uterus, increasing the risk of uterine cancer.

Despite the health risks, systemic estrogen is still the most effective treatment for menopausal symptoms. The benefits of hormone therapy may outweigh the risks if you're healthy and:

• Experience moderate to severe hot flashes or other menopausal symptoms
• Have lost bone mass and either can't tolerate or aren't benefitting from other treatments
• Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian insufficiency)

Women who experience an early menopause, particularly those who had their ovaries removed and don't take estrogen therapy until at least age 45, have a higher risk of:

• Osteoporosis
• Coronary heart disease (CHD)
• Earlier death
• Parkinsonism (Parkinson's-like symptoms)
• Dementia
• Anxiety or depression
• Sexual function concerns

Early menopause typically lowers the risk of most types of breast cancer and ovarian cancer. For women who reach menopause prematurely, protective benefits of hormone therapy usually outweigh the risks.

To determine if hormone therapy is a good treatment option for you, talk to your doctor about your individual symptoms and health risks. As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. If you continue to have bothersome menopausal symptoms, review treatment options with your doctor on a regular basis.

 Further Reading:
Hormone therapy: Is it right for you? - MayoClinic.com

Care of the Morbidly Obese Trauma Patient

Medivision.com presents an excerpt from "Care of the Morbidly Obese Trauma Patient", with Susan M. Gallagher (RN, MSN, CNS) on a nurses' perspective on the challenges of caring for morbidly obese patients in a hospital setting. The full one hour educational video available at health-e-mall.com also features Blanca Crandall, Patricia S. Choban, MD and Rosaline Parson, RN, BSN, CEN, CCRN and covers ways to improve the physical, emotional, and social needs of obese patients; why patients are reluctant to accept care and how that impacts skin and wound care in the hospital setting; common, predictable and preventable skin and wound complications, care suggestions; the value of using appropriate equipment and the safety risks standard hospital equipment may pose for the obese patient.

Obesity is now recognized as a major health problem in the United States; over 32% of the U.S. population is obese and the problem is not limited to adults. Although increases in the prevalence of overweight and obesity have been observed around the world, the United States has the highest prevalence of obesity among the developed nations.

The number of hospitalizations in which obesity was noted on admission has increased significantly compared to the overall increase in hospitalizations for any condition. While obese individuals undergoing weight reduction surgery account for some of these patients, many of them also seek health care for treatment of co-morbidities such as diabetes, sleep apnea, or orthopedic problems or for matters unrelated to the obesity, such as trauma or childbirth. The morbidly obese patient presents particular challenges to nurses providing their care.
Earlier nursing literature on weight reduction surgeries cautioned nurses to have additional staff available to assist in providing care, and to assemble specialized equipment to cope with providing care and transferring a patient with a large body mass, yet the requirement of increased staff to provide care for the morbidly obese  has received only limited additional attention in the literature.

ICU physicians also need to be aware of physiologic changes occurring with obesity that become relevant during critical illness. Special challenges are encountered when caring for the obese patient in the ICU, including airway management, bedside procedures and testing, nutritional support, drug dosing and nursing care.

Contemporary Compounding in the Community Practice Setting

Medivision.com presents a segment from our 1 hour educational video "Contemporary Compounding in the Community Practice Setting", featuring Art Matthys, RPh; William Letender, MS, RPh; Dave Mason, RPh and Loyd Allen, PhD. The full length video is available on DVD or VHS from www.health-e-mall.com and covers the following topics: -Definitions of the pharmacy, manufacturing, compounding and triad, and areas where pharmacists can solve non-compliance problems using compounding services; -Lists the unique dosage forms that are available to healthcare professionals, and the factors that exempt pharmacists from the Federal Food and Drug and Cosmetic Act; -Demonstrates how pharmacists meet the unique needs of patients at their practice sites; -Demonstrates the value of compounding services in terms of patient compliance and patient needs; -Identifies areas of practice that could potentially benefit compounding; -Illustrates a course of action to take when filling a compounded prescription .

Pharmacy compounding is the practice of preparing personalized medications for patients, in which individual ingredients are mixed together in the exact strength and dosage form required by the patient. This method allows the compounding pharmacist to work with the patient and the prescriber to customize a medication to meet the patient’s specific needs.
With the advent of mass drug manufacturing in the 1950s and ‘60s the pharmacist’s role as a preparer of medications changed to that of a dispenser of manufactured dosage forms, and most pharmacists no longer were trained to compound medications. However, the “one-size-fits-all” nature of many mass-produced medications meant that some patients’ needs were not being met and compounding has recently experienced a resurgence as modern technology, innovative techniques and research have allowed more pharmacists to customize medications to meet specific patient needs. Trained pharmacists can now personalize medicine for patients who need specific strengths, dosage forms, flavors or ingredients excluded from medications due to allergies or other sensitivities.

Two particular areas in which compounding has shown particular benefits are preparations for pain medications and pediatric prescriptions. 

Pain is the most common symptom for which individuals seek medical help. Many commonly prescribed, commercially available pain relief medications help the symptoms associated with chronic conditions such as arthritis, fibromyalgia and other nerve and muscle pain, but they can also result in unwanted side effects such as drowsiness, dizziness or stomach irritation. Many patients taking these medications come to accept these conditions as part of daily life, but they may find a better solution through pharmacy compounding.
Pharmacy compounding can provide alternate methods of delivery to make the medication easier; instead of a capsule or tablet, pain medications often can be compounded as dosage forms such as topical gels, creams or sprays that can be applied directly to the site of the pain and absorbed through the skin. Other delivery options may include a custom-flavored troche that dissolves under the tongue, a nasal spray, or a suppository.
These dosage forms may bypass the gastrointestinal tract, providing optimal results with less GI irritation and help patients who have difficulty swallowing pills. On many occasions, multiple medications can be combined into a single dose providing greater convenience for the patient. And because patients vary in size, symptoms and pain tolerance, commercially available medications sometimes may not provide the appropriate dosage strength for an individual patient; through compounding a prescriber and pharmacist can customize the dosage to the exact amount the patient requires and find a dosage form that best suits the patient’s needs.

Pediatric patients are especially suited for custom compounded prescriptions. For various reasons, commercially manufactured drug forms sometimes may not meet the needs of every child. Compounding can benefit young patients in a variety of ways.
Many children refuse medication because of its texture or color, or simply because they know it is medicine. But compounded medications may often be transformed into colorful, pleasantly flavored dosage forms  dispensed in childproof packaging. Compounding pharmacists can enhance the taste and color of a medication without changing the medication’s effectiveness, and utilize custom delivery forms such as
lollipops, gummy treats, topical gels or effervescent drinks. Some compounded medications can be administered using special pacifiers or bottles for infants.

1 in 10 US Parents Don't Follow Vaccination Schedule

About 13% of parents are skipping or delaying their children's immunizations and following an "alternative" vaccination schedule that puts kids at serious risk.

A recent internet survey which included 748 parents of kids between six months and six years old. Of those, 13 percent said they used some type of vaccination schedule that differed from the CDC recommendations. That included refusing some vaccines or delaying vaccines until kids were older -- mostly because parents thought that "seemed safer." In addition, two percent of parents refused any vaccination altogether, according to findings published in Pediatrics.

The survey,  conducted by researchers at the University of Michigan in Ann Arbor, evaluated 748 responses. The parents ranged from 18 to 59 years old, but most were ages 30 to 44. The results were comparable to an earlier, larger study by the CDC.

Parents were most likely to skip vaccination against H1N1 (swine flu) and seasonal flu, the study says. Parents were least likely to skip the polio vaccine. Researchers also noted that white parents were more likely to follow an alternate vaccine schedule, as were families who didn't have a regular doctor.

Skipping or spacing out vaccines dramatically increases the risk of illness, the study says. Children whose parents opt out of one or more vaccines are 22 times more likely to contract measles and nearly six times more likely to contract whooping cough, according to background research cited in the study. Unvaccinated babies are particulary vulnerable, because newborns are at greater risk of complications from many infections. Health officials are concerned about the trend: unvaccinated people have fueled an outbreak of measles, which sickened nearly 200 people in the first eight months of this year, according to the Centers for Disease Control and Prevention. The USA also has battled outbreaks of whooping cough and mumps in the past two years.

The patterns among those not following the recommended schedule varied. Among them:

• 17% said their child did not get any vaccines.
• 53% said they didn't get some vaccines.
• 55% said they delay some vaccines until older than the recommended age.
• 36% said they wait longer between multiple-dose vaccines than is recommended.
• 22% said they got each part of the measles, mumps and rubella vaccine separately.

The vaccines most likely to be refused:

• H1N1 influenza, refused by 86% of those on the alternative schedule
• Seasonal influenza, 76%
• Chickenpox (varicella), 46%

Another expert sees reason for concern about the 13%. "People who refuse vaccines tend to be clustered geographically," says Saad Omer, PhD, MPH, MBBS, assistant professor of global health, epidemiology and pediatrics at the Emory University Schools of Public Health and Medicine and the Emory Vaccine Center.
That, in turn, can create what he calls a ''critical mass" of people to trigger a disease outbreak.
"There is a reason why there is a schedule," says Omer. "The risk of preventable disease is not constant. One of the reasons we give vaccines at a certain age is the children are vulnerable at a certain age."
Another problem, he says, is that as parents spread out the vaccinations, the risk of not completing the recommended ones increases.

The CDC maintains a schedule of recommended vaccines on its web site, www.cdc.gov/vaccines/recs/schedules/child-schedule.htm

Electronic tattoo 'could revolutionise patient monitoring'

11 August 2011,  BBC News

Researchers have developed ultrathin electronics that can be placed on the skin as easily as a temporary tattoo, and hope the new devices will pave the way for sensors that monitor heart and brain activity without bulky equipment, or perhaps computers that operate via the subtlest voice commands or body movement.
Flexible electronics have been around for a few years; one approach is to write circuits onto materials that are already flexible, another is to make the circuits themselves flexible. In 2008, for example, engineers at the University of Tokyo created a conductive material that looked a bit like a fishnet stocking. Made of carbon nanotubes and rubber, it could stretch by more than a third of its natural length, possibly enough to make robots become more agile.
The problem with these past attempts, says materials scientist John Rogers of the University of Illinois, Urbana-Champaign, is that none of them has been as stretchy and as bendy as human skin.
Now, Rogers and his colleagues at Urbana-Champaign and other institutions in the United States, Singapore, and China have come up with a form of electronics that almost precisely matches skin's mechanical properties. Known as epidermal electronics, they can be applied in a similar way to a temporary tattoo: you simply place it on your skin and rub it on with water (see video). The devices can even be hidden under actual temporary tattoos to keep the electronics concealed.

Researchers hope it could replace bulky equipment currently used in hospitals:
A mass of cables, wires, gel-coated sticky pads and monitors are currently needed to keep track of a patient's vital signs. Scientists say this can be "distressing", such as when a patient with heart problems has to wear a bulky monitor for a month "in order to capture abnormal but rare cardiac events".
In one study the tattoo was used to measure electrical activity in the leg, heart and brain. It found that the "measurements agree remarkably well" with those taken by traditional methods.
Smaller, less invasive, sensors could be especially useful for monitoring premature babies or for studying patients with sleep apnoea without them wearing wires through the night, researchers say.