Re: Drugs For The Heart 8th Edition Free Download
Emmanuelle Riker
Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of an organ in the body, both have serious harmful effects, and both are, in many cases, preventable and treatable. If left untreated, they can last a lifetime and may lead to death.
Even relatively moderate drug use poses dangers. Consider how a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy that affects many lives. Occasional drug use, such as misusing an opioid to get high, can have similarly disastrous effects, including impaired driving and overdose.
The initial decision to take drugs is typically voluntary. But with continued use, a person's ability to exert self-control can become seriously impaired. This impairment in self-control is the hallmark of addiction.
Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control.12 These changes help explain the compulsive nature of addiction.
As with other diseases and disorders, the likelihood of developing an addiction differs from person to person, and no single factor determines whether a person will become addicted to drugs. In general, the more risk factors a person has, the greater the chance that taking drugs will lead to drug use and addiction. Protective factors, on the other hand, reduce a person's risk. Risk and protective factors may be either environmental or biological.
Biological factors that can affect a person's risk of addiction include their genes, stage of development, and even gender or ethnicity. Scientists estimate that genes, including the effects environmental factors have on a person's gene expression, called epigenetics, account for between 40 and 60 percent of a person's risk of addiction.27 Also, teens and people with mental disorders are at greater risk of drug use and addiction than others.28
Eating fish can protect against heart disease but many people don't eat enough to be effective. In November, an FDA panel recommended broader use of a prescription-strength fish oil drug Vascepa for people at higher risk of heart disease. Enn Li Photography/Getty Images hide caption
There's growing evidence that taking a very high dose of purified fish oil, delivered in a prescription pill, can help prevent heart attacks and strokes among people who have elevated risks. The amount of fish oil in the daily recommended dose of the pill is the equivalent of eating about eight to 10 servings of salmon a day.
In early November, an advisory panel to the FDA voted unanimously to approve expanded use of the prescription drug, Vascepa, which is made from one type of omega-3 fatty acid, called eicosapentaenoic acid, or EPA for short. The oil is extracted from sardines and anchovies, and then purified.
Now, the drug may soon be approved for use for a much wider group of Americans: people who've already had a heart attack or stroke, as well as people who have Type 2 diabetes and an additional risk factor such as high blood pressure.
"The panel felt very strongly that this fish oil product [Vascepa], taken in addition to statins, reduced cardiovascular disease," says Peter Wilson, a professor of medicine at Emory University, who was on the FDA advisory panel.
Evidence comes from a clinical trial that included about 8,000 people who had established cardiovascular disease or diabetes and other risk factors. One group of participants took 4 grams of the fish oil drug per day; others took a placebo. The trial lasted nearly five years.
"The trial showed convincing evidence for reduction of heart attack, stroke and and cardiac-related death, approximately a 25% reduction," Wilson says. The results were published in the New England Journal of Medicine.
"Some studies show benefit, some not," explains Dariush Mozaffarian, a cardiologist who is dean of the Friedman School of Nutrition Science and Policy at Tufts University. He says almost all the studies have tested relatively low doses, such as 1 gram a day.
"Pharmaceutical drugs are regulated by the FDA, so the manufacturing has to meet high standards, so you can be sure that when you take it you are getting the amount listed on the label, and it is safe and free of impurities," says Cecilia Low Wang, another member of the FDA advisory panel and a professor of medicine at the University of Colorado School of Medicine.
The new study, paid for by the company, included more than 17,500 people in 41 countries. Participants were age 45 and older, had a body mass index of 27 or higher and were tracked for more than three years on average. They took typical drugs for their heart conditions, but they were also randomly assigned to receive weekly injections of Wegovy or a dummy shot.
The drop appeared to be fueled primarily by the difference in heart attacks, but the number of serious health complications reported were too small to tell whether the individual outcomes were caused by the drug or by chance.
The Wegovy group also saw drops in key markers of heart disease, including inflammation, cholesterol, blood sugars, blood pressure and waist circumference, noted Dr. Martha Gulati, a heart expert at Cedars-Sinai Medical Center in Los Angeles. Changes in those markers began early in the study, before participants lost much weight.
About a third of all study volunteers reported serious side effects. About 17% in the Wegovy group and about 8% in the comparison group left the study, mostly because of nausea, vomiting, diarrhea and other stomach-related problems.
The medications are often not covered by private health insurance or subject to strict preauthorization requirements. Medicare, the government health plan for older Americans, is prohibited from covering drugs for weight loss alone. But drugmakers and obesity treatment advocates have been pushing for broader coverage, including asking Congress to pass legislation to mandate that Medicare pay for the drugs.
Results from the latest study and others that show the obesity drugs have a direct effect on costly health problems could be a factor in shifting the calculus of coverage, said Dr. Mark McClellan, former chief of the Centers for Medicare and Medicaid Services and the FDA. In 2006, Medicare was allowed to cover weight-loss surgery to treat the complications of severe obesity, if not obesity itself, he noted.
Professor of preventative cardiology & internal medicine at Griffith University, Ian Hamilton-Craig said excessive salt intake could raise blood pressure, which increases the risk of heart disease and stroke.
The study authors tracked over 1.2 million people for 13 years. They found people taking these medicines had a 16% increased risk of heart attack, stroke or vascular death than those taking the non-sodium versions of the same drugs.
The ATLS global educational curriculum provides a systematic, concise approach to trauma patient care in an effort to improve trauma outcomes around the world. The content and skills taught in the course are designed to be adaptable to all health care settings for the care of patients and are intended for the immediate management of the injured patient. The knowledge gained through the course allows participants to rapidly and accurately assess the patient; stabilize and resuscitate by priority; determine the needs of the patient and whether those needs exceed the resources of the treatment facility; arrange for appropriate definitive care; and ensure that optimal care is provided.
Modifications occur in both format and content with each new edition. This article offers a chapter-by-chapter description of what is covered in the 10th edition of ATLS, which was published in January.
A key tenet of the curriculum that remains the same is the ABCDE (airway, breathing, circulation, disability, exposure) algorithmic approach to the rapid initial evaluation of the injured patient. Despite the revision of this approach adopted in the combat and disaster setting, ATLS continues to support prioritizing the rapid assessment and treatment of life-threatening airway and breathing problems ahead of circulation problems. No evidence-based data were identified that justified a modification to this approach in the care of civilian patients.
The rapid assessment of the airway by determining the ability of the patient to speak and answer questions appropriately, in addition to verifying adequate ventilation and circulation, has long been a key element in the treatment of trauma patients. In this edition of ATLS, drug-assisted intubation has replaced rapid sequence intubation (RSI) as a broad term that describes RSI and the use of medications to assist with intubation of a patient with intact gag reflexes.
Recognizing shock is one of the greatest challenges in the management of the injured patient. During the early management of the injured patient, shock is identified by evidence of end-organ hypoperfusion present on physical examination. Later, simple adjunctive measures can be added to improve the precision of the diagnosis. The classification of shock based on easily measured physiologic variables is attractive.
A table relating physiologic variables with hemorrhage severity has been a part of several ATLS editions. However, some recent literature challenges the accuracy of the classification of hemorrhage and the attributable clinical findings. A retrospective review of severely injured patients in the German trauma registry found variability in clinical findings and ATLS shock classification. The study found base deficit (BD), easily available in many settings, decreased the variability. BD and the need for blood transfusion or the massive transfusion protocol are now included in Table 3.1, reproduced here as Table 1.
The initial resuscitation with crystalloid fluid still begins with a 1 liter bolus of warmed isotonic fluid. Large volume fluid resuscitation is not a substitute for prompt control of hemorrhage. Infusion of more than 1.5 liters of crystalloid fluid has been associated with increased mortality. Early control of external hemorrhage is pivotal to the management of the injured patient. Though direct pressure is the first measure instituted to control external hemorrhage in civilian trauma, military experience supports the judicious use of tourniquets placed above the area of injury in uncontrolled hemorrhage. Massive transfusion is defined as the transfusion of more than 10 units of blood in 24 hours or more than four units in one hour.
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