All you have to do is check the want ads every Sunday to realize that medical professionals are in high demand across the country.  Whether you want to be a nurse, a doctor, a pharmacist, a dentist, or a surgeon, the prognosis for job growth among diagnostic professionals is healthier than ever.

If you are intrigued by the medical field and just love taking care of people, you just may have a promising future as a CNA, a certified nursing assistant. The good news is, that it will not take years for you to obtain the certification to make this career of your dreams come true. You can find a CNA certificate training program just about anywhere, so you probably don’t even have far to go for a nursing school.

Helping people with daily activities like getting dressed, washing and eating is part of the job of a CNA. These could be both elderly people, or younger people with a range of disabilities. It is pretty standard to need a combination of theory and physical practice before completing an exam, but the specifics can change from state to state.

In anywhere from 1 1/2 months to 3 months, your CNA training will need to review subjects like nutrition, nursing skills, anatomy and physiology and how to control infections. You will get the best exposure to the field and what this job is all about in your hands-on training section. ,000-,000 a year is a typical salary although it varies depending on the facility you work in.

Many certified nursing assistant training programs cooperate with medical clinics so that they can recruit the first certified graduates available. Nursing Homes, mental health facilities, assisted living homes, and private individuals often have a need for certified nursing assistants. A CNA’s chief mandate is to fully assist the nurses on duty. Ideally LPN’s or RN’s can focus on where they are most needed since you will be administering a lot of the direct patient care.

The great news is that, many of the CNA certificate training programs have online components. You will still need your clinical training, as per many states’ requirements, but you can at least take your theory online. You then have the chance of working at the same place you got your hands-on training in, as they may ask you to stay on when the program is complete and you have your certification.

A certified nursing assistant will have a fulfilling career that will keep you on your toes

Stacy is professional researcher and now a days doing research on medical education in USA. she is co-author and administrator of Medical Schools Sacramento: an informative blog about medical institutions of Sacramento

Galichia Heart Hospital has signed agreements with Blue Cross & Blue Shield of Kansas and with Coventry Health Care of Kansas, making the hospital an in-network provider for both insurance companies.

Galichia CEO Stephen Harris said Tuesday that the hospital had been negotiating with both companies for several months. Galichia signed a contract with Preferred Health Systems earlier this year.

Harris called the contracts “a sentinel event in our history.”

“We’ve been talking to them for a long time,” he said.

Blue Cross and PHS are the two largest insurers in the Wichita market; the sale of PHS to Coventry is pending.

For years, Blue Cross and Wesley Medical Center had an exclusive contract, and PHS and the Via Christi Health system had an exclusive contract. PHS is owned by Via Christi Health.

The PHS-Galichia contract signed earlier this year was the first in a series of announcements as the market opened.

Wesley Rehabilitation Hospital recently announced that it had signed an agreement to become an in-network facility for PHS as of Jan. 1.

It already contracts with Blue Cross and Coventry.

Blue Cross now has contracts with Wesley, Via Christi, Galichia, Kansas Heart Hospital and Wesley Rehab. PHS has contracts with Via Christi, Wesley, Galichia, Kansas Medical Center in Andover and Wesley Rehab. Coventry has contracts with Wesley, Galichia, Wesley Rehab and Via Christi-Our Lady of Lourdes.

PHS made Galichia an in-network hospital when the contract was signed; the other agreements will take effect in 2010.

Harris said, “I think it makes business sense for Blue Cross to have a broad network, and it make business sense for Coventry” to have a bigger network in the Wichita area.

The opening of the market, he said, “allows the hospitals to compete with quality and service and support rather than just because they have the contract…. It’s good for us because we’ll be able to level the playing field, which we’ve always wanted.”

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Within the medical industry, there are thousands of different types of careers to choose from. According to the Bureau of Labor Statistics, “Employing 14 million people in 2006, the medical industry projects an estimated three million more jobs by 2016.” One medical career that is both well-paid and rewarding is a Pharmacist. When compared to other medical careers, the salaries of pharmacists are very lucrative. An additional benefit of a having a career as a pharmacist is that the Bureau of Labor Statistics projects that “careers in pharmacy will increase by 22 percent over the next 10 years.”

Pharmacists are licensed medical professionals that are involved with the dispensing of drugs and medications to patients. As well, they educate patients on dosages and reactions associated with a particular drug. A pharmacist has to be an expert in calculating drug dosages so there is a lot of responsibility that comes with the career. Although the pharmacist is an expert in compounding, formulating, storing, and dispensing pharmaceutical drugs and medication, the pharmacist’s direction is changing and evolving to include such areas as drug therapy for patients and the interactions of these drugs and their side effects, teaching diabetic patients how to inject insulin, assisting hypertension patients with managing their blood pressure, as well as the treatment of certain conditions such as colds, flu, and skin irritations…etc. They also offer community health programs such as testing blood pressure and cholesterol levels, and promoting health issues such as a healthy diet and exercise. Pharmacists must earn a Pharmacy Degree from an accredited college or school of pharmacy and acquire a license in order to work as a pharmacist.

A career as a pharmacist is very financially rewarding. As a pharmacist acquires more experience, salary will increase. The normal starting salary for pharmacist is about $80,000. After so many years working as a pharmacist, salary can be over $100,000. Salary can vary according to the industry where the pharmacist is employed. Pharmacists can be employed in retail pharmacies, pharmaceutical companies, hospitals, drug store chains…etc. The highest salaries can be found in the retail pharmacy industry. As well, Pharmacists often receive special incentives when they accept a job position. These incentives can be a bonus that can be up to $15,000. The bonuses normally come with a contract where the pharmacist will stay at a particular job for a specified number of years

Pharmacists are devoted to fulfilling the health care requirements of their patients. Pharmacy is a profession that is expanding in new directions to meet the health care needs of all members of the community. The pharmacist is involved in a broad range of health roles in a community and it is a career that is expanding to a variety of medical areas. For instance, one fourth of pharmacists work in hospitals and many pharmacists now work for pharmaceutical companies on new drug development.

Pharmacists play a fundamental role in the community and provide an important function as educator to the public. A career as a pharmacist is a financially and personally rewarding career with many opportunities for those who enjoy attending to the health care needs of the community.

While a pharmacy career can be fairly fulfilling, it is also quite competitive to obtain pharmacy jobs. In order to be one of the outstanding candidates for pharmacist jobs, you not only need the qualifications, but also the passion.

Health insurance is a kind of agreement between you and your insurance company that you need in case you get sick and need medical help. Unfortunately, usually people get interested in their health insurance only when something bad happens – only to find out that they have a 3,000 deductible or some important things you need (such as a wheelchair) are not included into the policy. Before you get a health insurance policy it’s recommended to review all of them and find the one that will give you most coverage.

Almost all health insurance policies cover emergency services and whenever you have to go to the hospital and receive the treatment the cost will be covered less the deductible specified in the policy. A basic deductible for emergency room treatment can start at $50 and it should be mentioned that insurance companies are very particular about conditions that can be considered an emergency. If you have flu it’s probably not going to be covered, unless your fever is way too high. Your health insurance is likely to cover annual check-ups, with their number specified by the policy. If you need to see your doctor more often than it’s usual you need to look for a health insurance policy that soul be more comprehensive and would provide you with more coverage. Vision services are usually covered, including one visit to the eye doctor a year, while glasses and contact lenses are not covered in most cases, especially if you have a basic health policy.

Hardware coverage is required for people wearing glasses or contact lenses. Certain diagnostic services that are considered to be reasonable by your insurance company (X-rays and other procedures intended to diagnose certain conditions). You may not qualify for coverage if the symptoms you have are not considered to be serious enough – so it’s always best to call our insurance company with this question. If you are planning to have a surgery a pre-authorization from you insurance company is required. The necessity of the surgery will be evaluated by the doctor and the request is supposed to be sent by your health care provider. This can take up to 30 days. So, in general you need to keep in mind that most insurance companies will not be paying 100% of your medical costs, and in most cases you will have to co-pay from 10 to 50% of each medical bill you get. Before you purchase a health insurance policy it’s worth thinking about how much you are ready to pay out of your pocket for the service provided, and if that amount is not too high be ready to purchase a standard or above health insurance policy with maximum coverage.

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In this article, a doctor from Maryland (who is one of our clients at Dentist profits) will share to you how Dentist Profits have helped him as a dental practice consulting act. He will share to you the benefits of joining our club and how it has helped him achieve success in his business as a dental practice consulting act. And this is something that we focus specifically at our dental practice consulting website!

Here’s how Dentist Profits have helped him in his dental practice:

When I joined Ed’s club as a dental practice consulting act, I asked myself: “What am I doing here?”. And I look at the others and asked myself: “What do they do?”. And then I decided to just do it… just join the club! Having my dental practice acquisition on 2002 (my practice did okay from 2002 – 2005), I joined in Silver in September 2005, and attended my first Super Conference in October 2005. At first I didn’t really get it. And then finally a year later I got it and I started marketing like a madman! And now, this year, what I’m targeting to do is getting a 5 1/2 times collection over our 2002 numbers. It’s pretty good and I’m very happy about it! And I attribute this explosive growth to Dental Profits, the “Leapfrog” Mindset, teamwork and implementation.

As I have managed my dental practice, I always followed the Ed’s “Leap Frog Theory” as an act of dental practice consulting; the mindset that I had to change within myself, getting my team on board and moving into the right direction and implementation. I always found out that you must always lead in your dental practice, and you have no choice if you are a doctor!

Now, one of the most powerful things that we did (and I have learned) in the Super Conference way back October 2005, is to really set goals in your dental practice. As an act of dental practice consulting, Ed told me to set a goal for my dental practice, and I told him: “My father was hoping for a million dollar practice!”. That’s huge, I know. So my goal then was to get such a practice… but Ed told me: “Why not double it? Go up for a 2 million dollar practice!”. And Ed’s suggestion was okay for me. But he said: “Or better yet, add another 20% to your goal!”. So it was like around a $2.5 million practice. Honestly, I wasn’t able to think that big before, but it changed my way of thinking, and it just opened up a whole new world for me! So right now, I’m doing very well in my dental practice; I have set my goals as high as I can get them. I always go for the best goal that I can have for my dental practice just as Ed has taught me… and all I can say is that it was really worth my while joining in to Dental Profits!

Log on to our dental practice consulting website, www.dentistprofits.com and get a free CD and Book titled, “The Underground Secrets Of Attracting High Quality New Patients Who Pay, Stay, & Refer!”.

If you have chronic halitosis you may wonder just how your toothpaste, mouthwash and other oral products worsen your bad breath; after all, aren’t you told to keep a regular routine of good oral hygiene in order to combat your bad breath?

It is true that one should keep one’s mouth clean to keep bad breath at bay. Most cases of halitosis are caused by a buildup of bacteria or germs in the mouth or throat, and bacteria always have a foul odor. When you neglect your oral hygiene you allow these things to fester inside your mouth. However, some oral products may worsen your bad breath in a few ways. One is by making the inside of your mouth very dry. Products that contain peroxide or baking soda are notorious for doing this. When your mouth is dry, all that bacteria and germs stick to your teeth, gums and tongue. When they stick, they stay. So even after you brush and rinse you are making those elements linger in your mouth. This is just one way that oral products may worsen your bad breath.

Another way that oral products may worsen your bad breath is if they contain alcohol, for the same reason as mentioned above. Alcohol may very well kill germs and is often advertised in many oral products as a way to do that, but once the germs are killed the mouth is very dry and sticky. Mouthwashes are especially notorious for this, and what is unfortunate is that many people use mouthwash after they brush and rinse, so the alcohol lingers in the mouth. These alcohol rich oral products may worsen your bad breath if you fail to rinse your mouth out with plain water after using them, and unfortunately very few people actually do that.

An additional way that oral products may worsen your bad breath is if they are very harsh on your teeth, gums, tongue and skin inside your mouth. One way that bacteria and germs linger in your mouth is if you have tooth decay, gum disease, or cavities. Products that are very harsh can wear away at the enamel of your teeth and cause all these problems. It’s best to use products that are much gentler and that don’t contain alcohol. Don’t hesitate to ask your dentist for a recommendation.

Do you know that you can freshen your bad breath with vitamins? Learn how you can use hydrogen peroxide to remove bad breath effectively and much more with our excellent free resources on how to eliminate bad breath.

It is often true that after a drama of especially the colossal kind, we can look back years later and find something good about it. For instance, if I didn’t lose my car keys that rainy day and asked a stranger for help, I might not have met my husband. Or if her husband didn’t commit suicide, she would still be married to someone who abuses his child.

I’ve often read articles in magazines where the writer decrees “If it wasn’t for cancer, I would not have grown so deeply on a spiritual and emotional level”.  Some say “It brought me and my husband much closer together”. Others say “It was the greatest gift I ever received”.

It seems so easy to find the gift when the disaster is over. The real trick is to find the blessing WHILE the fiasco is raging. Ultimately, as far as my experience goes, I feel better after a while. Maybe it takes months, maybe weeks, maybe hours. Why not shorten the suffering by finding the benefit sooner, rather than later?

I remember when my CD shuttle was stolen from my car boot in 98. I had acquired this fantastic piece of equipment, which was going to make my life so much more pleasant, only a week before. My most prized CD’s were in it. The feeling of disappointment, anger, resentment and just pure lust for revenge were overpowering when I discovered this loss. A day later I simply decided that I will ultimately get over it – why waste any more time on something that couldn’t be changed?

Bill Harris of Centrepointe Technology puts it so appropriately: “The amount you suffer in life is directly related to how much you are resisting the fact that things are the way they are“.

So… how come it’s so hard to find the blessing in disguise in the moment of distress? Our emotions are powerful and are driven by chemicals produced in the body. Often they can lead to the fight-flight response or make us ‘freeze’ in time. Some of us even get addicted to the chemicals produced and keep creating situations to produce those ‘drugs’ for us.

I wish I had known EFT back then! My distress was already shorter than my friends anticipated, and it could’ve been reduced to minutes if I’d had this self-help tool at my fingertips. In an EFT session, longstanding emotional distress can disappear in minutes, as if a fairy has just swung her magic wand. By getting rid of the distressing emotion, we are able to open up to the gifts in the situation.

EFT (short for Emotional Freedom Techniques) is an emotional version of acupuncture – no needles necessary!  And by the way, if you grimaced at the thought of a needle, an EFT session is almost guaranteed to rid you of that fear…

Important energetic and stress-relief points on the body are lightly tapped, while the skilled practitioner helps you discover all the bits and pieces surrounding your ‘issue’. This ‘issue’ can range from health challenges, to emotional turmoil, anger, resentment, fears, phobias… in fact, one of the motto’s of EFT is “Try it on Everything”.

I’ve been working with EFT in my alternative health practice for 3 years and have seen consistent, clear results – enough to simply know that it works. If it hasn’t worked for you yet, it’s mainly because of one of the main mistakes beginners can make – not being specific enough with the issue. The EFT manual is freely downloadable from the official EFT website, and anyone can learn for free. However, there is an art to delivering it skilfully for the best results. Contact me for more information.

Liesel passionately supports her clients to grow, learn and shift from limitation to empowerment.

www.clearspace.za.net

Don’t belittle the crises of an untreated gum infection. The crises make up, developing heart disease to unanticipated births and from diabetes to osteoporosis, making the associated health complications of overlooking gum infection remedy broad. Yet, how could you be susceptible of heart disease from gum infections?

The growth of bacteria in the mouth is the cause of gum infections, initiating the gums around the teeth to become inflamed and can even influence the root of the teeth in the bone. Engaging in proper dental hygiene can prevent this most likely serious condition. Meanwhile, once you’re having cure against gum disease or periodontitis (the progressed state of gum disease), there can be various antibiotics for gum infections that can prove beneficial against the bacteria causing the infection.

Based on the research of the American Academy of Periodontology (AAP), gum disease causes the tissues around the tooth to break down. The empty space made becomes a place for bacteria to multiply and increase. To control the infection, the gums then turn out inflamed and susceptible to bleeding.

As the infection creates additional swelling and when the space in between the teeth and gum widens, periodontal bacteria has the chance to go into the blood stream while the gums bleed. Stored oral bacteria may lead to inflammation in the bloodstream and arteries, and blood clots which are the symptoms of possible heart issues.

It can be a surprise for you to know that there are antibiotics for gum infections. Bacteria could regularly be impervious to antibiotics. It can be a lot tough to handle the infection when the medication isn’t taken as prescribed or when it’s stopped, because this makes the bacteria more difficult to contain and prevented.

If you haven’t responded well to first cures or have a rare and strong form of gum disease called Necrotizing Ulcerative Gingivitis (NUG), then you’re provided with antibiotics for gum infections. These antibiotics for gum infections can also be provided to those with weaker immune systems or those that have serious health problems.

If your tooth doctor does provide you an antibiotic, you may take a pill or your dentist might pack pockets of gum infection with gel, powder, or small pill-like dissolving chips of antibiotics for gum infections. These are costumarily put in place for 7-10 days, and then any left-over residue is removed. Antibiotics for gum infections are used together with scraping and planning – a procedure of removing hard tartar formations and bacteria from the tooth to gumline.

Those who suffer from diabetes and gum infections, understand that the bacteria may get into your bloodstream via brushing, flossing or when the gum bleed. It is believed that the bacteria mix with the blood, making it hard to maintain a balanced blood sugar level. Additionally, women who have gum infections could initiate and insite premature labor on pregnancy.

Because the bacteria in gum infections isn’t just localized to an inflamed areas, it could be important for everyone, especially high risk groups namely pregnant women, those with diabetes and those who are at risk for heart disease, to cure gum disease promptly and to maintain scheduled dental checkups in order to avert future health complications. Consult you dentist about antibiotics for gum infections to help you eliminate and avoid the hazards that go with having gum disease.

Stop pain and irritation brought about by gum infections using proper prevention and oral care. Know more with OraMD and stop gum infections, halitosis, gingivitis and even periodontal disease.

Save Your Health With Antibiotics For Gum Infections

Karyu Gilbert is an expert on health related topics. He has written many articles regarding skin care, dental health and many others.

OPERATIVE MEDICAL ASSESSMENT OF DENTAL PATIENT

Author:

Dr. Altaf H Malik

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Co authors: 

Dr. Ajaz A Shah

Associate Professor and Head,

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Dr. Suhail Latoo

Lecturer

Department of Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

Dr. Rubeena Tabasum

Resident

C.D Hospital, Srinagar.

Dr. Shazia Qadir

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

INTRODUCTION

Knowledge regarding the patient’s medical condition is of utmost importance in patient management and care pre and post surgically. A detailed medial history will give the practitioner all the necessary. Relevant information regarding the patient’s general condition as well as physical status

PHYSICAL STATUS CLASSIFICATION SYSTEM

In 1962, the American Society of Anesthesiologist adopted the ASA physical classification system. This system identifies the medical risk to a patient undergoing a surgical procedure. The classification system is as follows:

ASA I:        A patient without systemic disease; a normal, healthy patient

ASA II:       A patient with mild systemic disease

ASA III:      a patient with sever systemic disease that limits activity, but is not incapacitating

ASA IV:     a patient with incapacitating systemic disease that is a constant threat to life

ASA V:       A moribund patient not expected to survive 24 hours with or without surgery.

ASA E:       Emergency operation of any kind, E precedes the ASA number, indicating the patient’s physical status.

CARDIAC DISEASE.

Although all types of cardiac diseases are at high-risk of serious complications when undergoing surgical procedures under general anesthesia, certain conditions like unstable angina, congestive cardiac failure , valvular septal  defects, and myocardial infarction increase the risk four folds. A history of bypass, angioplasty or valve replacement is of significant importance. Although cardia disease is not an absolute importance. Although cardiac disease is not an absolute contraindication, the surgeon should weigh the benefits against the risks before deciding the choice of anesthesia.

Preoperative Investigations

1.       Routine chest radiograph-posteroanterior view. 2.       Electrocardiogram Echocardiogram

4        Stress test

Blood investigations like lipid profile and bleeding time, clotting time and prothrombin time and index in case the patient is on long-term anticoagulants

Preoperative medications

If the patient is a case of rheumatic heart disease or has undergone valve replacements, a suitable antibiotic prophylaxis must be given. If the patient is on injection penidura every three weeks, the surgery should be scheduled immediately after the scheduled dose to reduce the risk of infective endocarditis. Patients on long term anticoagulant therapy should discontinue the anticoagulants at least 4 to 5 days prior to surgery with the physician’s consent. If discontinuation of oral anticoagulant therapy is not advisable, the patient should be shifted to intravenous anticoagulants like heparin. The patient’s bleeding time and clotting item is checked on the day of surgery after omission of the anticoagulant.

Intra and Postoperative management

All the patients should be monitored intra and postoperatively by means of ECG, pulse oximeter, and arterial line. A central venous pressure (CVP) cut down may be performed if necessary. The patient should be maintained on intravenous cardiac drugs till oral feeds are given Fluid overload should be voided, especially in cases of congestive cardiac failure. The fluid volume can be judged by the CVP.

HYPERTENSION

Hypertension is considered to be the elevation of the blood pressure above 140/190 mm of mercury.

Uncontrolled hypertension can have the following surgical and anesthetic complications.

It reflects on the cardia status of the patient, thereby increasing the an aesthetic complications It reflects on the cardiac status of the patient, thereby increasing the anesthetic risk to the patient. It causes excessive bleeding from the operation site, thereby complicating the surgical procedure as well as significant blood loss for the patient.

Preoperative investigations

Chest radiograph-poster anterior view for detecting cardiac enlargement. ECG USG of the kidneys Opthalmic evaluation for pailledema and retinal haemorrhage.

Renal function tests (Blood urea nitrogen serum creatinine and serum electrolyte).

Preoperative Medication and Management

The patient’s blood pressure should be monitored and controlled within the normal permissible limits prior to the surgical procedure. If the patient is on antihypertensive, the morning dose of medication prior to surgery must be given with sips of water.

Intra and Postoperative Management.

The blood pressure should be monitored continuously intra and postoperatively. The patient’s cardiac status should also be monitored on the ECG machine and on the pulse oximeter. Antihypertensive must be continued intra and postoperatively. If the patient is on diuretics, the patient must be supplemented postoperatively with intravenous potassium supplements. If the procedure is performed under local anaesthesia, then local aneasthetic without adrenaline or bupivacaline, which does not have any significant effect on the cardiac status, is to be used.

RESPIRATORY DISEASE

Respiratory disease can be categorized obstructive and infiltrative pulmonary diseases. Obstructive pulmonary disease includes chronic obstructive pulmonary conditions like, asthma, chronic bronchitis, pneumothorax and emphysema. Infiltrative disease is inclusive of diseases that cause inflammatory changes in the alveolar walls. Any respiratory disease is first characterized by dyspnea.

The patient with decrease in the pulmonary reserve poses a great risk for procedures under general anaesthesia. The patients should be asked for a thorough history of beedi/cigarette as well as past history of tuberculosis. If the patient is suffering from tuberculosis, then details of his / her drug regimen and duration of treatment is asked. From the surgeons point of view the most important aspect is the patient’s respiratory reserve and his ability to tolerate general anaesthesia. If the patients treated under local anaesthesia, the broncho- dilator inhaler should be kept ready for use in case of an emergency.

Preoperative Investigations

Routine chest radiograph – posteroanterior view. Pulmonary function tests. Blood investigations like arterial blood gases. Sputum AFB / culture. Bronchoscopy, if required

          The patient should be counseled to discontinue beedi / cigarette smoking prior to the procedure. Any acute infection should be treated by antibiotics. The patient should be on bronchodilators pre, intra and postoperatively. The patient must carry his / her inhaler with him / her for use in case of an emergency.

Intra and Postoperative Management

Arterial blood gas monitoring should also be carried out intra and postoperatively. Avoid fluid overload Blood loss should be replaced by whole blood or packed cells to avoid decrease in the oxygen carrying capacity of blood.

RENAL DISEASES

Patients with renal disease like renal failure, acute glomerulonephritis, and nephrotic syndrome pose a significant surgical risk. Disturbances in the renal function leads to changes in the acid base balance, serum calcium and phosphorous levels, fluid retention, and electrolyte concentration. A patient with chronic infection may develop sepsis postoperatively. These patients also have associated hypertension secondary to fluid retention and anaemia.

Preoperative investigations.

Renal profile-blood urea nitrogen, serum cretinine, serum electrolytes. Creatinine clearance test. Serum calcium and phosphorous. Urine analysis-physical and microscopic. USG of the kidneys. Renal Doppler studies. Radionuclide scanning for renal clearance time

Intra and Postoperative Management

Fluid balance, acid-base balance and electrolyte balance must be closely monitored. Renal profile tests must be performed intra as well as postoperatively. Blood replacement is done by washed packed cells. Potassium overload during fluid replacement is to be avoided. The patient should be covered with broad-spectrum antibiotics to prevent sepsis. As most antibiotics are excreted through the kidneys, only a few have been proved safe for use. Amoxycillin, doxycycline and minocycline are a few recommended antibiotics.

MANAGEMENT OF RENAL TRANSPLANT PATIENT

1. Renal transplant patient’s come under American society of Anaesthsiologist Risk category III (Requiring medical consultation)

2. Stressed  Reduction:

Patient should obtain proper rest the night before.

Appointments should be kept short.

Barbiturates and Benzodiazepins can be used in normal amounts.

Nitrous oxide-oxygen combination is an excellent anxiolytic.

Maintain a non-threatening environment.

Morning appointment.

Consultation with the patient’s physician for the need of additional steroids.

Steroids dose can be doubled the day before on the day of, 2 days after dental procedure.

Graft survival -> 90% at one year with overall mortality rate 5%

Patients need to immuno suppressed with a corticosteroid plus steroid sparing drug (azathioprin) cyclosprim to prevent raft rejection.

Treatment:

Those with symptoms of Cronic Renal Failure –Treatment like CRF

Immuno suppressed-> steroid + antibiotic prophylaxis.

Hepatitis common- patient kept away from source of infection

Candidiasis.- Topical nistatin, amphoterecin, miconazole

Patients on immunosuppressive therapy with renal transplantation have a risk of developing – malignant disease, (lymphoma, skin, cervical and lips cancer) leukoplakia, kaposis sarcoma

Drugs that can be used in Renal transmutation patients

SaferDrugs- Cloxoacillin, Penicillin, Minocycline, Erythromycin, 

                      Refampicin, Lignocaine. Chloralhydrate,Diazepam

Fairly Safe- Ampicicilin,amoxicillin,Benzylpencillin cotrimazole,  

                    metronidozole,codein, Barbiturates, Phenothiazins.

Less safe- Aminoglycosites cephalosporin, pracetamol, acetoaminophin,  

                 pethidine, opiods, antihistamins,

Avoid Drugs Tetracyclin , sulphonaimides, NSAID’s and Aspirin

HEPATIC DISEASE

Preoperative Investigations

Liver enzymes—SGOT (serum glutamic oxaloacetic transaminise),

 SGPT (serum glutamic pyruvic transaminse).

Total bilirubin, direct and indirect bilirubin. Serum albumin. Serum alkaline phosphates. Bleeding time and clotting time. Prothrombin time and index. USG liver. Australia antigen test.

Intra and Postoperative Management

Avoid unaesthetic gases that are metabolized in the liver, like halothane. Correction of coagulation deficiencies by IV vitamin K, fresh frozen plasma transfusions. Careful intra and postoperative management of blood volume, cardiac output, urine volume and co0mposition. Potassium supplementation during fluid replacement. Appropriate precautions and sterilization techniques to prevent transmission of disease in a carried of viral hepatitis.

DIABETES MELLITUS

Diabetes mellitus is caused by an absolute or relative deficiency of insulin in the body can be classified into type 1(insulin dependent) and type 2 (insulin dependent). Type 1 is more commonly seen in young patients and type 2 in adults. A patient can be classified as a diabetic when his fasting glucose levels are constantly above 140mg/dl.

The nature of problems faced by the surgeon during the management of a know diabetic patient are as follows.

Optimal blood sugar levels are to be maintained during the procedure as well as postoperatively to prevent hypoglycemia or hyperglycemia and ketoacidosis. Both the conditions may be life-threatening to the patient. The patient is prone to infections and has to be given adequate pre and postoperative broad-spectrum antibiotic coverage to prevent infections. The patient may have additional systemic complications like renal failure, cardiac disorders, and ophthalmic problems and generalized vascular disease due to long-standing diabetes.

          For surgical purpose a diabetic can be classified in three groups:

Sugar levels controlled by diet and oral hypoglycemic. Sugar levels controlled by insulin. “Brittle diabetes”, usually of juvenile onset, whose metabolic needs is labile and have sequel of long-standing disease such as renal failure, retinopathy, and generalized vascular disease.

Elective surgeries can be usually performed without complications in the first two types. In the third type, although the management remains same, amore rigid control is to be exercised intra and postoperatively.

Preoperative Investigations

Routine chest radiograph-posteroanterior view. Electrocardiogram Blood investigations like:

          a. Blood sugar fasting and postprandial

          b. Glucose tolerance test

          c. Renal profile (BUN, SC,SE)

Urine sugar.

          If the patient is on oral hypoglycemics, he/she must be shifted to insulin on the day of surgery. The general principle for the management of the patient under general anaesthesia is to provide at least 200gm of carbohydrate with adequate insulin to cover this need.

Sugar Levels and Insulin Dose

Sugar Levels (mg %)             Insulin dose

80 – 120                                  Plain 5% dextrose (D)

120-180                                   4 units in 5% dextrose

180-250                                   8 units in 5% dextrose

250-300                                   14 units in 5% dextrose

300 and above                         14 units in normal saline

Intra and Postoperative Management

Check the patient’s blood and urine sugar levels on the morning of surgery with the help of hemoglucose strips and urostrips or glucometer. Prepare a sliding insulin scale to be followed intraoperatively based on the patient’s sugar levels. Pre and postoperative broad spectrum antibiotic coverage. Intra and postoperative close monitoring of the bold and urine sugar levels. Prevents the patient from going into ketoacidosis or hypoglycemia.

Signs of hypoglycemia: The patent is apprehensive restless, agitated, the skin is moist and pale and there is tachycardia. The patient then lapses in to coma.

Treatment : In a conscious patient, ora carbohydrates are given to collect the glucose levels. In an unconscious patient IV administration of 50% glucose solution restores consciousness in 5 to 10 minutes or 1mg glucogon IM restores consciousness in 15 minutes.

Signs of diabetic ketoacidosis : Vomiting, tachypnea, Kussmaul (deep, rapid breathing at regular intervals) breathing, dehydration and circulatory collapse.

Treatment: Administration of insulin to normalize body metabolism and restoration of body fluids and electrolytes.

6.Shift the patient at the earliest possible to his regular oral feeds and antidiabetic medications.

THYROID DISORDERS

Patients having disorders can be broadly divided in to 3 groups – hypothyroid, euthyroid and hyperthyroid. Out of these euthyroid patients pose no risk for any surgical procedures. In both hypo and  hyperthyroidism, elective surgery is best postponed  till the patient is euthyroid.

The sense of hypothyrodism are water and mucopolysacharide retention, slowing of metabolic process leading to bradycardia, constipation, letheargy and hypothermia. Untreated hypothyroid patients respond poorly to stress and proceed in myxedema coma.

Hyperthyrodism leads to a hypermetabolic state in the body resulting in catabolic state with tachycardia, diarrhea and heat intolerance. If this patient is subjected to stress, he goes in to what is known as “thyroid storm”, which is a state of metabolic hyperactivity lasting for 24 to 48 hours. It is a severe exacerbation of the signs and symptoms of hyperthyroidism and is usually accompanied by hyperpyrexia. The condition is life-threatening and requires control of hyperpyrexia, tachycardia and cardiac failure.

Preoperative investigations

1        Thyroid hormone levels – T3, T4, TSH

2        Serum electrolytes

3        Serum proteins

4        Radionuclide thyroid scan to study the gland.

Intra and post operative management.

1. Monitor the Hormone levels intra and postoperatively

2. Continuous monitoring of vital parameters, blood pressure, pulse and  

    Temperature.

3. Check for signs and symptoms of hypo / hyperthyroidism

4. Continuous monitoring of cardiac function, especially during thyroid crisis. Infuse thyroid hormone if the patient shows signs of hypothyroidism.

5. If the patient is in a thyroid storm, treat by cooling the patient, intravenous, infusion of glucose and IV fluids, glucose and corticosteroids

6. Use narcotic agents and anesthetic medications judiciously in hypothyroid patients as they can have a profoundly depressing effect.

ADRENAL DISEASE.

Two common adrenal disorders that have to be dealt with during surgical procedures are cushings syndrome (overproduction ) and addisons disease (under production)

The symptoms of cushings syndrome are diabetes, sodium and water retention, potassium excretion, hypertension and fat redistribution. the patient also has a tendency to osteoporosis, poor wound healing and purpura formation. During surgery attention must be paid in maintaining optimum levels of carbohydrates in the body, sodium and potassium ion levels and the blood pressure. There may be postoperative problems of bleeding and delayed wound healing.

          Underproduction can occur due to adrenal suppression due to exogenous steroids or due to a disease of adrenal origin (Addison’s disease).Usually any patient who has received steroids for longer than two weeks within a year prior to surgery should be considered as a candidate for adrenal insufficiency.

Preoperative investigations

1.Renal profile.

2.Serum electrolytes.

3.Fasting Blood Sugar.

4.Platletcount.

5.Coagulation profile.

Patients with adrenal insufficiency should be supplemented with adequate exogenous steroids prior to procedure to help the patient combat with stress

Intra and Postoperative Management.

1.Continuous monitoring of the vital sings.

2. Adequate intravenous corticosteroid supplementation to prevent adrenal crisis.

3. Maintain fluid and electrolyte balance.

4. Monitor blood sugar levels.

NEUROLOGICAL DISORDERS

Neurological disorders can be categorized into patients with cerebrovascualar disorders, seizure disorders and  patients with head injury. the main factors of consideration in these patients is to maintain adequate cerebral perfusion intra and postoperatively and to control any seizure episode during this period. Patients with seizure disorders usually do not pose a great problem for intra operative management except for  cases of status asthamaticus, where there can be life-threatening  complications. The surgeon should weigh the risks and benefits infarcts, aneurysms, and areteriovenous malformations are very high-risk candidates and are absolute contraindications for surgical procedures.

Preoperative investigations

1.Routine skull radiographs-posteroanterior and lateral views.

2.CT scan/MRI brain.

3.EEG.

4.Liver function tests.

          If the patient is an epileptics, adequate control of seizure episodes must be achieved prior to the surgical procedure. The anticonvulsant must be continued till the morning of the surgery. The morning dose is given with sips of water.

Intra and Postoperative Management

1.The patient should be given intravenous anti-convulsants intraoperatively.

2.Postoperatively the patient should be shifted to his normal dose of anticonvulsants at the earliest possible.

3.Throughout the procedure, hypotension/hyoxia is to be avoided and an adequate cerebral perfusion is to be maintained.

DISORDERS OF THE HAEMOPOLETIC SYSTEM

Disorders of the haemopoietic system can be grouped into anaemias, leucocyte disorders and coagulation factor abnormalities(haemophilia).Anamias include iron deficiency anemia, thalassaemia, sickle cell anaemia; and leucocyte disorders include leucocytosis and agranulocytosis.

Any disturbance in the haemopoietic system

1. Predisposes the patient to prolonged bleeding during any surgical procedure, which cannot be controlled by routine hemostatics.

2. May cause severe internal bleeding due to blunt injury following intubation, a condition if unnoticed may pose a life-threatening complication.

3.Leukemic and thalassemic patients may be on repeated blood transfusions and may have liver disorder due to excessive deposits of hemosiderin.

4.the rate of postoperative infection and delayed wound healing is also very high, especially in agranulocytosis, leukemia and anaemia.

Preoperative investigations.

1.Complete blood count

2.Bleeding time and clotting time.

3.Prothrombin time and index

4.Partial thromboplastin time.

5.Coagulation factor level assay (in case of factor abnormalities).

6.Platlet count

7.Haemoglobin.

8.Liver function tests

          Prior to the procedure, the patient’s blood counts must be built up to the normal values by transfusion of whole blood, packed cells, plasma or plasma components and clotting factors. For a hemophiliac, the factor VIII level should be raised to at least 50 to 70 percent prior to the procedure. Once the blood levels are normal, the patient can be treated as a normal patient with regards to surgical kept ready for transfusion intraoperatively, if required. In case of leukemics, the patient should be covered with broad-spectrum antibiotics pre and postoperatively.

Intra and Postoperative management

1. Avoid undue trauma to the tissues during any procedure performed.

2. Avoid entering deep tissue spaces blindly, thereby preventing any internal bleeding.

3. Complete hemostasis must be achieved prior to wound closure.

4. Intraoperative transfusion of blood/blood products, if found necessary.

5. Monitoring of hemoglobin, complete blood counts intra and postoperatively.

6. Maintain adequate blood volume throughout the procedure and at the same time avoid cardiac overload.

7. Monitor the vital parameters closely for any changes in the fluid volume indicated by the pulse and blood pressure.

8. Postoperatively the patient may be maintained on systemic oral coagulants like vitamin K for 3-5 days.

9. Cover the patient with adequate broad spectrum antibiotics.

10. Avoid medications that can exacerbate the  underlying condition, especially in agranculocytosis.

          In view of the rise in blood borne transmission of diseases like AIDS, hepatitis B and hepatitis C, the government has made it compulsory for testing of all the three viruses before storing the blood in the blood bank. But the decision to transfuse blood and blood products must still be made judiciously weighing the risks and benefits.

Management of a Hemophiliac Patient

Classically hemophilia is of two types, hemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency).The disorder is a sex-linked recessive trait.Approximatley 50 percent of the female offspring’s are carriers of the disorder and 50 percent of the male offspring’s have the clotting disorder. these patients have  the clotting disorder. These patients have a tendency to bruise easily and prolonged bleeding.

The successful management of a hemophiliac is dependent on the adequate maintenance of the antihaemophilic globulin. The normal AHG level is 50 to 100 percent. In a hemophiliac, for good hemostasis, the factor level must be 20 percent above normal, though a normal level is also acceptable.

Thromboplastin regeneration time not only determines the factor VIII deficiency but also distinguishes it from factor IX deficiency. Factor VIII replacement can be provided through blood, plasma, fresh frozen plasma, and cryoprecipitate. The latter is the replacement choice as it offers only the deficient factor.

Management

1. Build up factor VIII level to 50 to 70 percent.

2. Avoid injecting into deep tissue spaces, i.e. avoid block techniques. Use infiltration anaesthesia.

3. Traumatic extraction surgical procedure.

4. Avoid unnecessary trauma to the soft tissues, avoid suturing, if not required.

IMMUNOCOMPROMISED PATIENTS

Immunocompromised patients can be grouped into patients having deficiency in cell mediated, humoral immunity, neutorphils complements, patients on immunosuppressive drugs like chemotherapeutic agents and steroids and patients suffering from long-standing debilitating conditions like diabetes and nutritional deficiencies.

          These patients are highly susceptible to infections and must be given

broad-spectrum antibiotic coverage for the same.

Preoperative investigations.

Complete blood count

 Liver function tests

Renal function tests

Serum proteins

Blood sugar levels.

Urine analysis.

Routine chest radiograph.

Intra and Postoperative Management

The management will vary according to the condition the patient is suffering from. Usually it is almost impossible to correct the causative factor and the treatment is usually supportive only.

Constant monitoring of the vital parameters.

Broad spectrum antibiotic coverage.

While handling HIV infected patients, special care must be exercised to prevent the transmission of the disease.

AUTOIMMUNE DISORDERS

The group of autoimmune disorders includes systemic lupus erythematosus, scleroderma, collagen disorders rheumatoid arthritis, Shjogren’s syndrome, polyartertis nodosa,etc. These patients may have significant cardiac, renal and bone marrow impairment, which may contraindicate elective surgery. The patients, whenever possible must be operated during their remission phase. A few of these patients may be on long-term corticosterioid therapy, therefore, precautions to prevent adrenal insufficiency must be taken.

A few of these patients have loss of flexibility in the joints, especially the thoracic cage and neck joints, thereby posing problems in intubation and ventilation. In posing problems in intubation and ventilation. In scleroderma, the patients have a restricted oral opening as well as restricted expansion of the chest wall.

Patients with collagen disorders may also have delayed postoperative wound healing.

PREGNANCY AND LACTATION.

Every female patient in the childbearing age must be asked for history of pregnancy of missed menstrual cycles. Great care must be taken when dealing with the pregnant patient since the surgeon has to treat not only the mother but also prevent any undue harm to the fetus. It is safe to perform procedures under local anaesthesia in the second trimester. In the first trimester, there is a risk of stress related abortion as well as teratogenicity, while in the third trimester there is a risk of stress induced while in the third trimester there is a risk of stress induced early labor. General anaesthesia is a contraindication in the third trimester, unless it is a life saving emergency the third trimester, unless it  is a life saving emergency procedure. In the first and second trimesters care must be taken to avoid fetal anoxia.

Again, the risks and benefits must be weighed prior to the procedure, The mother should be fully explained about the risks before performing any procedure. The mother should be fully explained about the risks before performing any procedure. teratogenic drugs like tetracyclines,salicylates, and chloramphenicol are best avoided. Amoxycillin, cloxacillin, ampicillin and paracetamol can be safely prescribed.

CONCLUSION

Concluding this chapter, a few points need to be highlighted, which will define a basic protocol to be followed during the management of a medically compromised patient.

A through knowledge of the patient’s medical background must be obtained.

The surgeon should also have knowledge about the medications taken by the patient and the regularity of the patient in taking the same.

A written consent for the surgical procedure has to be obtained from a specialist in the field prior to the procedure.

Adequate and necessary preoperative investigations must be performed.

The patient should be explained about the risks and benefits of the procedure with regards to his general condition and a witnessed written consent for the procedure, as well as high-risk consent should be obtained from the patient.

          The operation theater must be well-equipped with functional life support systems and an updated emergency trolley in case of an emergency. The same applies to the postoperative recovery room.

The decision of whether or not to operate lies with the surgeon and he/she must make his/her choice judicious weighing the pros and cons with respect to surgical benefits and anesthetic risks

Exploring the fascination humans have with the fantasy characters in literature and film will plunge you into a world of inconsistencies and contradictions. What lies in wait are the ingredients for varieties of concocted tales that rely upon the imaginative tastes of the author’s pen. And from that pool of boundless fiction, many an author has produced a delicious treat that appears in the form of a mysterious, yet easily recognized figure. Though they vary from pen to pen, we are delighted to experience any new creative version of – the vampire.

It is the allure of vampires itself that has puzzled many. Of all the fantasy characters available to us – werewolves, witches, elves, fairies, dragons, etc – what keeps the vampire on top? Why is the vampire king of the world? Or, I should say – worlds. Vampires seem to dominate the world of horror, the world of fantasy and sci-fi and now vampires even rule the world of romance. Amazing flexibility for a character that was originally so stereotypically stiff.

Famed wordsmith, Stephen King has proven that you can take any object and make it interesting or scary. From a car to a dog to a puppet. Just let your twisted imagination run wild. So, why do so many choose to reinvent the vampire?

Perhaps, familiarity among the viewing public. Widespread popularity and the ability to “set up” the reader for a unique twist by playing on their belief that they think they know where you’re going.

Since the beginning of horror, we were able to feed from the four basic food groups – Frankenstein, The Mummy, The Werewolf and Dracula. Over the decades and with the advancements in film, these “monsters” have been reanimated many times over, often receiving a new coat of paint. Yet, none have seen the light of day more often – or in a more formats – than the vampire. We don’t even refer to him as Dracula anymore.

Calling on a plethora of spotty folklore and nearly a century of urban legends, the vampire now seems to be able to appear in any form or situation and the general public will welcome him/her with lustful glee. For some reason, vampires are just cool.

Breaking down the lust for vampire lore, we find it based in two realms of non-reality. Some authors choose to build their vampire characters from the magical aspects we’ve become accustomed to. Avoiding the sun, silver and garlic. Interacting with Weres and Fairies. Probably one of the more prolific versions of this example is the Sookie Stackhouse series by Charlaine Harris.

Now an HBO series called True Blood, this modern tale puts the girl-next-door Sookie into a world where vampires have “come out” and live openly among humans. Harris sticks to many of the traditional vampire cliches, keeping them out of the sun and afraid of silver. Sookie interacts with vampires like you might do so with the mailman. It’s a fun and compelling series that draws you into many scary situations involving werewolves and fairies in addition to your favorite vampires. Borderline believability built on a solid platform of magical nonsense. Entertainment at its best for most vampire lovers.

By comparison, some writers lean more heavily upon the supernatural world to provide you with a darker dish of vampire stew. From the realm of angels and demons, many vampires are portrayed as tortured souls cursed to live in endless damnation. Reviled and oppressed, often hunted into extinction, these more traditional vampires represent the age-old good vs. evil story lines. Demonic creatures of the night, preying on helpless humans.

Falling somewhere between these two categories, The Vampire Diaries attempts to prey on recent surges in vampire popularity by appealing to the younger audience. It does an acceptable job of offering traditional vampire clichés while relying on magical rings to let its heroes move around during the daylight.

L.J. Smith has penned a series that is both timely and fun. While at times, it’s hard to take it seriously; it does capture the romantic side of the vampire genre with the boy-loses-girl-boy-finds-new-girl-who-looks-like-old-girl plot.

Which brings us back to the allure of vampires. Why do we never tire of a good long-toothed tale? Whether you prefer the magical side or the darker supernatural side of these tales, you can still accept them for what they are. Just good entertainment.

Since vampires don’t really exist and we have countless legends to draw upon, we  can reinvent vampires in endless variations. But, it’s the well-written versions that really suck us in. It’s the romanticism of the genre. The dark creatures who live just outside reality, preying on our natural fears and skepticisms. And, who among us hasn’t admitted, at least once, that it might be fun to become a vampire? To live forever. To control your prey with eye-contact. To flash those deadly fangs and spread bone-chilling fear with just a look.

And then, of course, there’s the sex. The sexual attraction of creatures with exceptional strength, stamina and animalistic desires. To be smitten and bitten at the same time. For some, it’s a breath-taking fantasy.

With vampire tales firmly planted in either magic or supernatural ground, an unexpected anomaly has risen to the top of pop culture in the form of The Twilight Saga. Vampire purists have decried Stephenie Meyer’s artistic creation as fluffy gibberish. This is unfair, at best. After all, she’s an author. Using her imagination and creative flair, she has produced the unthinkable.

Vampires without fangs. Venom laced teeth. Skin that sparkles in sunlight but doesn’t burst into flames. Twilight falls into the magical pool. There’s nothing demonic or supernatural about it. And, Meyer includes shape-shifters as the vampire’s nemesis. Definitely the magical genre.

A tip of the hat to Stephenie Meyer for producing a compelling love story with new twists on overworked vampire myths. To do so is her right as an artist. And, the fact that she did it so well has been validated by the raging social phenomenon we know as The Twilight Saga. Who could have imagined it? Likeable vampires. Vampires that young females around the world want to fall in love with. Vampires that young males want to emulate. Yes, even vampires without fangs are cool.

Having established that vampire lore springs from magic or darker supernatural origins, one wonders when an author might attempt to offer a third option. Could these mysterious creatures exist in a reality-based world?

A new novel, JUICE: Revolution has cast aside the roots of the vampire genre and created a new one. Injected with humor, sexual tension and real-world situations, JUICE follows its protagonist through encounters with “foreigners” who display unusual, yet slightly recognizable traits.

Readers will find themselves enjoying a more believable journey into a world where the unexpected becomes plausible – without the help of magic. JUICE: Revolution spirals toward reality-based revelations that are both shocking and horrifying. Hang on while Revolution exposes an alternate reality that will literally rewrite the history of the world, as we know it.

Michael Clutton lives with his wife and grown daughter in the Smoky Mountains of North Carolina. They have 3 small dogs.
When he’s not working on his next book, he follows NASCAR racing and poker. Find out more about him at http://www.michaelclutton.com or follow JUICE progress at http://mpclutton.blogspot.com and share your comments.