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By Q. Steve. University of Massachusetts at Amherst.

Itallowsalterationof tors occur in a genetically susceptible individual setting the muscle use purchase 100mg zoloft otc depression symptoms youtube, the contact areas and the blood dy- up a sustained inammatory response purchase 25 mg zoloft overnight delivery bipolar depression 3rd. It is of most use in younger r Twin studies demonstrate a signicantly higher con- patients with a good range of movement and rela- cordance in monozygotic compared with dizygotic tive preservation of the intra-articular cartilage buy 100mg zoloft free shipping mood disorder prevalence. Hip and knee replace- difference diminishes after the menopause reinforcing ments are the most successful; however purchase zoloft 100 mg depression definition investopedia, there is a the possibility of a role for sex hormones. Sixty per mal range of movement is difcult to achieve and centofpatientswhodeveloprheumatoidarthritishave the prostheses are prone to failure. There are some genetically inherited disorders with early onset os- Pathophysiology r Tcells: Antibody-mediated activation of T cells trig- teoarthritis, which have a much worse prognosis. Cytokine cascades result in a com- Rheumatoid arthritis bination of angiogenesis and cellular inux, leading to transformation of the synovium with the ability to in- Denition vade cartilage and connective tissue. The transformed Rheumatoid arthritis is a chronic multisystem, inam- synovium may also activate osteoclast-mediated bone matory disorder with a characteristic symmetrical pol- erosion. Age r Rheumatoid factors are autoantibodies to the Fc por- Peak age of onset 30 55 years. It is r There is often associated muscle weakness and gen- thought that they provoke further inammation and eralised osteopenia due to immobility, which may be activate the complement system. Clinical features (extra-articular) r Long-standing inammation and effusion distends See Fig. The overall result is joint instability and continued use leads to joint deformity. Investigations r r Blood: Anaemia (usually normochromic normo- Afteravariableperiod,synovialinammationmaybe- come quiescent. Degradation of scleral collagen (blue Lung: appearance) which rarely may Pleural involvement is common and progress to perforation (scleromalacia may result in pain and effusions. Skin: Haematology: Rheumatoid nodules are found in 20% Splenomegaly and neutropenia in of patients. Anaemia may occur due to fibroblasts with an outer coat of chronic disease iron deficiency, or lymphocytes. Methotrex- r Because of immobility and steroid therapy patients ate is normally used as rst line, other agents include with rheumatoid arthritis are at high risk for develop- sulphasalazine, gold and hydroxychloroquine. Bis- is slow, 10 20 weeks, and all have some degree of phosphonate therapy should be considered in high- toxicity. Synovitis of the spine and large arthrodesis (joint fusion) may be performed for in- joints may occur, and there is both synovitis and enthe- tractable pain at the elbow or wrist; however, there sopathy at the sacroiliac joints. Atlantoaxial sub- intervertebral disc becomes calcied and forms a bony luxation may require surgical stabilisation. As 4 Joint replacement has signicant postoperative these extend up the spine, calcication causes rigidity morbidity but can be an effective longer term treat- and a typical bamboo appearance on X-ray. Clinical features Prognosis Patients develop a gradual onset of episodic low-back The disease generally progresses insidiously in the ma- painandmorningstiffness. Thereisalossofnormallum- jority of cases although most patients experience periods barlordosisduetomusclespasmandsacroiliacjointten- of exacerbation and quiescence. Movement of the spine is restricted in all planes and a limitation of chest expansion may occur. Acute anterior uveitis, aortic regurgitation and (spondyloarthropathies) apical lung brosis are known extra-articular features. Ankylosing spondylitis Denition Ankylosing spondylitis is a chronic inammatory arthri- tis predominantly affecting the axial skeleton, causing pain and progressive stiffness. Pathophysiology r Patients should be encouraged to remain active, avoid Synovitis is histologically the same as that of rheumatoid prolonged bed rest and avoid lumbar supports. Phys- arthritis, although bone resorption is sometimes promi- iotherapy involvement is important. Itislikelythatboththeskinlesionsandthearthritis r Pain and morning stiffness are treated with non- are immunologically mediated. Fivepatternsofarthritis osteotomy may be helpful in patients with severe cur- are seen: vature. There is a wide range of severity: In over 85% there is 3 Symmetrical rheumatoid-like polyarthritis. Psoriatic arthritis Investigations Denition r Blood tests may show raised inammatory markers, Achronic inammatory arthritis occurring with psori- anaemia of chronic disease and presence of autoanti- asis. Other features include 1% of population have psoriasis of which 5% will get periostitis, bone resorption, sacroiliitis and spondyli- arthritis. Second line agents include methotrex- Typically there is an abrupt onset of asymmetrical lower ate and ciclosporin. Achilles ten- have been shown to be effective in reducing the pro- dinitis and plantar fasciitis may also occur. Surgical intervention may have been preceded by a clinical urethritis, prostatitis, prove necessary. Prognosis It is not clear whether any medical intervention has Investigations disease-modifying potential. X-rays are initially normal but may show erosions and features Reactive arthritis similar to ankylosing spondylitis. Denition Management Acute or chronic synovitis that occurs less than 6 weeks Although unlikely to affect the course of arthritis, an- following infections with various organisms, including tibiotics are given for ongoing urethritis. Ophthalmol- Chlamydia, Yersinia, Salmonella, Shigella and Campy- ogy referral is essential for uveitis and the arthritis is lobacter species. Reiter s syndrome is a form of reactive usually managed with nonsteroidal anti-inammatory arthritis with the triad of arthritis, uveitis, and urethritis. The few patients who develop a chronic arthritis are treated as for rheumatoid arthritis. Denition An enteropathic arthritis, sacroiliitis, ankylosing Sex spondylitis or rarely hypertrophic osteoarthritis in as- M > F sociation with ulcerative colitis or Crohn s disease. Sex 1:1 Pathophysiology In early synovitis there is intense hyperaemia with in- Aetiology ammatory inltration. Enteropathicarthritisisaseroneg- into a number of chromosomal loci in relation ative non-erosive synovitis. Intra-articular creased cytotoxic T-cell reactions, increased helper steroid injections may be of value. Connective tissue disorders It is thought that these defects may trigger a cascade of events resulting in the production of autoantibod- Systemic lupus erythematosus ies. Prevalence Pathophysiology 40 per 100,000 in United Kingdom, wide geographic The mechanism by which the aetiological factors inter- variation (1:250 American black women). Systemic symptoms include general malaise, Aetiology fever(sometimeshighandswinging)anddepression(see r Genetics: Up to 60% concordance in monozygotic Fig. Currently studies are underway oles, venules and capillaries) pleura and joint capsules. Diffuse proliferative: crescents in Heart (25%): most severe cases (proteinuria, Pericarditis with small effusions casts, renal failure & hypertension) (tamponade is rare), mild myocarditis iii. Mesangial (usually benign and may remain subclinical) Musculo-articular (95%): Small joint symmetrical pain and myalgia are common but joints appear normal on examination. Immune complex deposition in skin at the dermal cardiolipin is a component of the antigenic mixture epidermal junction, kidney and blood vessels. These occur mainly in the r Nonsteroidal anti-inammatory drugs are rst-line deepveinsofthecalf. Arterialthrombosisinthe r Antimalarials are used for systemic symptoms, refrac- cerebral vessels, coronary, renal and mesenteric arter- tory arthritis and skin disease. Cyclophosphamide is more toxic but may be used in severe diffuse proliferative nephritis or severe neu- Investigations ropsychiatric lupus. Prognosis Generally a good prognosis, chronic forms of the disease Management are seen. Patients with renal or neuropsychiatric involve- Anticoagulation with aspirin for mild cases and war- ment have a worse prognosis.

Tests for endocrine function in this context taken in case of allergy or risk of contrast nephrotoxicity cheap zoloft 25mg otc depression boredom. Pancreatic polypeptide is raised in all of useful for assessing focal lesions of the liver purchase zoloft 25 mg otc anxiety bible verses, staging of these types of tumour and see page 222 for specic malignancy order 50 mg zoloft with visa depression symptoms for elderly, and it is more sensitive for pancreatic le- tests purchase zoloft 100 mg line depression psychiatric definition. Pancreaticcalcicationmay times used as a non-invasive alternative to endoscopic be seen in chronic pancreatitis. Complications include haemorrhage, patients suspected of having biliary obstruction, stone bile leakage, bacteraemia and septicaemia. This is followed by checked and a sample sent to transfusion for group real-time radiography. Hepatitis B and C surface antigen sta- Further diagnostic and therapeutic manoeuvres: r tus should be known. Percutaneous aspiration of an abscess is approximately 1%, but this rises with any therapeutic occasionally performed. Haemorrhage and perforation occur less cedure the patient should rest on their right side for 2 commonly. Ascending cholangitis may be prevented by hours in bed and should gently mobilise after bed rest antibiotics, which are given prophylactically to all pa- for a further 4 hours. However, in many cases of Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected. For example in obstruc- The liver is composed of several segments, as dened tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and prole is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later. Laparoscopic cholecystectomy requires three or four cannulae inserted through the anterior abdominal wall, Caudate and for visualisation and access with operative instruments. Open cholecystecomy often requires quite a long stay Gallbladder Hepatic artery and in hospital, possibly a week or more, whereas laparo- portal vein scopic cholecystectomy may be conducted as a day case. Laparoscopic tech- This means that right hepatectomy, left hepatectomy nique reduces the incidence of respiratory problems and and extended right hepatectomy (right lobe plus cau- surgical site infection. The appropriate vessels for the segment(s) Disorders of the liver are ligated and divided before the segment(s) are dis- sectedawayfromtheremainderoftheliver. Carefuliden- Introduction to the liver and tication and ligation of biliary ducts and smaller vessels liver disease is required to reduce blood loss and therefore morbidity and mortality. Drainage is required postoperatively, to Introduction to the liver prevent bile from pooling intra-abdominally. It has two blood supplies: 25% of Cholecystectomy its blood originates from the hepatic artery (oxygenated) Surgical removal of the gallbladder and associated stones and 75% originates from the portal vein that drains the in the biliary tract may be by open surgery or laparo- gastrointestinal tract and spleen. Cholecystectomy is also considered in The functions of the liver are carried out by the hepa- younger patients with asymptomatic gallstones in or- tocytes, which have a special architectural arrangement. Blood enters the liver through the portal tracts, which Carcinoma of the gallbladder is treated by wider resec- contain the triad of hepatic artery, portal vein and bile tion, including neighbouring segments of the liver and duct. The lobule is classically used to Open cholecystectomy is usually performed through describe the histology of the liver (see Fig. Cholangiography may be used to The hepatocytes in zone 1 of the acinus receive well- visualise the duct system. The gallbladder is removed oxygenated blood from the portal triads, whereas the with ligation and division of the cystic duct and artery. The liver has multiple functions, which may be im- Aetiology paired or disrupted by liver disease: The causes of acute hepatitis: r Carbohydrate metabolism: The liver is one of the ma- r Acute viral hepatitis may be caused by the hepa- jor organs in glucose homeostasis under the control totrophic viruses (A, B and E) or other viruses such as of pancreatic insulin. Excess glucose following a meal Epstein Barr virus, cytomegalovirus and yellow fever is converted to glycogen and stored within the liver. The liver is also involved in the breakdown of amino acids producing ammonia, which is converted Pathophysiology to urea and excreted by the kidneys. Cellular damage results in impairment of normal liver r Fat: The liver is involved in synthesis of lipoproteins function: bilirubin is not excreted properly resulting in (lipid protein complexes), triglycerides and choles- jaundice and conjugated bilirubin in the urine, which terol. Swelling of the liver results in stretching of the liver capsule which may result in pain. However,itissometimesdiagnosed may be an enlarged, tender liver, pale stools and dark earlier than this. Stigmata of chronic liver disease should be looked for to exclude acute on chronic liver disease. Aetiology The main causes of chronic hepatitis: Microscopy r Viral hepatitis: Hepatitis B virus (+/ hepatitis D), Acute viral hepatitis has a histological appearance which hepatitis C virus. Complications Clinical features Fulminant liver failure, chronic hepatitis, and cirrhosis. Patients may present with non-specic symptoms (malaise, anorexia and weight loss) or with the compli- Investigations r cations of cirrhosis such as portal hypertension (bleed- Serum bilirubin and transaminases (aspartate ing oesophageal varices, ascites, encephalopathy). Asymp- Ultrasound may be needed to exclude obstructive tomatic patients with chronic viral hepatitis may be de- jaundice, if applicable. This includes careful uid balance, which is likely to progress rapidly to cirrhosis with adequate nutrition and anti-emetics. Where possible re- chronic inammatory cells inltrating the portal moval of the causative agent, e. Patients require se- to central veins or central veins to each other (bridging rial liver function tests (including clotting) to follow the necrosis). Pathophysiology Complications All the liver functions are impaired (bilirubin meta- Cirrhosis is the most common complication. Femini- Investigations sation in males and amenorrhea in females are common Chronic hepatitis is diagnosed by a combination of per- in alcoholic liver disease and haemochromatosis due to sistently abnormal liver function tests and the ndings alterations in the hypothalamic pituitary gonadal axis. Other investigations are aimed at diag- Reduced immune competence and increased suscepti- nosing the underlying cause and providing a prediction bility to infection also occur. Patients may present with complications such as bleed- ingfromoesophagealvaricesorencephalopathy. Patients Management withactivechronichepatitismaypresentwithfeaturesof r Symptomatic management includes adequate nutri- chronic liver disease before cirrhosis is established. The liver is usually enlarged, rm and irregular, but is shrunken Aetiology in late disease. The spleen may be enlarged due to Cirrhosis results from continued hepatocellular necro- portal hypertension. The cut surface shows nodules of liver tissue, r Alcohol accounts for more than 80% of cirrhosis in separatedbyneorcoarsebrousstrands. Other rare but impor- Grading system 1 2 3 tant drug-induced causes are halothane, isoniazid and rifampicin. Hepatic time (seconds encephalopathy is thought to be due to failure of the over control) liver to metabolise toxins. Serum amino acid levels rise Child Pugh grade A = score of 5 6; Child Pugh grade B = score affectingthebalanceofcerebralneurotransmitters. Hep- of 7 9; Child Pugh grade C = score of 10 15 atic dysfunction also results in renal failure (hepatorenal syndrome).

Manuscript collection standard citation with full name for authors Calderwood zoloft 25 mg fast delivery depression and exercise, Howard Black buy cheap zoloft 100mg line anxiety attack. Manuscript collection with organization as author Association of Military Surgeons of the United States generic zoloft 25mg without a prescription depression symptoms light headed. Manuscript collection with no author or compiler Collection concerning health resorts generic 100mg zoloft mastercard vitale depression definition. Manuscript collection title not in English Fonds du Conseil de Recherches Medicales. McFarland collection in aerospace medicine and human factors engineering [microfiche]. Fonds du Conseil de Recherches Medicales [Collections of the Medical Research Council]. Manuscript collection accompanied by material in another medium American College of Cardiology. Gertrude Henle is required to quote, cite, paraphrase, or publish any of the unpublished material during her lifetime. Proceedings of the History of Ophthalmology conferences held at the National Library of Medicine in March of 1988 and 1989. Books and Other Individual Titles in Audiovisual Formats Created: October 10, 2007. An audiovisual may be published in monograph form, such as a book on videodisc, or in journal form, distributed on videocassette or audiocassette. The extent or length of an audiovisual is an optional component of a reference that may provide useful information to the reader. Provide extent as the total number of physical pieces, such as 387 slides or 1 videocassette. Run time (also known as running- time) is the length of the film or program in minutes, such as 2 videocassettes: 140 min. You may provide more physical description details after the extent to give the reader additional information. For example, the size of an audiovisual can affect the equipment needed to view the item. If more information is needed, consult the case housing the audiovisual or any accompanying booklet or other documentation. Note that the rules for creating references to audiovisuals are not the same as the rules for cataloging them. Continue to Citation Rules with Examples for Books and Other Individual Titles in Audiovisual Formats. Continue to Examples of Citations to Books and Other Individual Titles in Audiovisual Formats. Citation Rules with Examples for Books and Other Individual Titles in Audiovisual Formats Components/elements are listed in the order they should appear in a reference. Author/Editor (R) | Author Affiliation (O) | Title (R) | Type of Medium (R) | Edition (R) | Producer, Editor, and other Secondary Authors (O) | Place of Publication (R) | Publisher (R) | Date of Publication (R) | Extent (O) | Physical Description (O) | Series (O) | Language (R) | Notes (O) Author/Editor for Books and Other Individual Titles in Audiovisual Formats (required) General Rules for Author/Editor List names in the order they appear on the opening screens or in the text accompanying text Enter surname (family or last name) first for each author/editor Capitalize surnames and enter spaces within surnames as they appear in the document cited on the assumption that the author approved the form used. Books and Other Individual Titles in Audiovisual Formats 697 American College of Surgeons, Committee on Trauma, Ad Hoc Subcommittee on Outcomes, Working Group. Collaborative research with communities: value added & challenges faced [videocassette]. Audiovisuals authors with particles or prefixes in their names (give as provided in the publication) 7. Audiovisuals with organization as author with subsidiary part of organization named 10. Audiovisuals with no authors found Books and Other Individual Titles in Audiovisual Formats 699 12. Moskva becomes Moscow Wien becomes Vienna Italia becomes Italy Espana becomes Spain Examples for Author Affiliation 12. New York: Society for French American Cultural Services and Educational Aid; 1991. Udalenie doli legkogo pri tuberkuleze [Lung lobe resection in tuberculosis] [motion picture]. Box 16 Audiovisual titles in more than one language If an audiovisual title is written in several languages: Give the title in the first language found on the opening screens of a videocassette, videodisc, or motion picture or the first few slides of a slide set or by listening to an audiocassette If the language cannot be determined there, look to the container of the audiovisual or other accompanying written material for clarification List all languages of publication after the date of publication (and extent if included) Separate the languages by commas End language information with a period Example: A plastic story: a history of plastic surgery [videocassette]. Box 17 Audiovisual titles ending in punctuation other than a period Most titles end in a period. Place the type of medium in square brackets and end title information with a period. Box 19 No audiovisual title can be found Occasionally an audiovisual does not appear to have any formal title; it simply begins with the text. In this circumstance: Create a title from the first few words or concepts expressed on the opening screens Use enough words to make the constructed title meaningful. Place [videocassette], [audiocassette], [motion picture], and similar types inside the period. Box 21 Non-English titles with translations If a translation of a title is provided, place it in square brackets Place the type of medium after the square brackets for the translation Example: Piccoli. Examples: Microhemagglutination assay methods in the diagnosis of syphilis [audiocassette + slide]. Case studies in human growth and development: a flexible instructional module [audiocassette + videocassette]. Case Western Reserve University, 706 Citing Medicine Health Sciences Communication Center, producer. Audiovisuals with more than one type of medium Edition for Books and Other Individual Titles in Audiovisual Formats (required) General Rules for Edition Indicate the edition/version being cited after the type of medium when an audiovisual is published in more than one edition or version Abbreviate common words (see Abbreviation rules for editions below) Capitalize only the first word of the edition statement, proper nouns, and proper adjectives Express numbers representing editions in arabic ordinals. Box 25 Both an edition and a version If an audiovisual provides information for both an edition and a version: Give both, in the order presented Separate the two statements with a semicolon End edition/version information with a period 710 Citing Medicine Examples: Epidural anesthesia [videocassette]. Box 26 First editions If an audiovisual does not carry any statement of edition, assume it is the first or only edition Use 1st ed. Box 28 Secondary author performing more than one role If the same secondary author performs more than one role: List all roles in the order they are given in the publication Separate the roles by "and" End secondary author information with a period Example: Baxley N, Dunaway C. Audiovisuals with authors and producer(s), editor(s), or other secondary authors 21. Audiovisuals with no place, publisher, or date of publication found Publisher for Books and Other Individual Titles in Audiovisual Formats (required) General Rules for Publisher Record the name of the publisher as it appears in the publication, using whatever capitalization and punctuation is found there Abbreviate well-known publisher names with caution to avoid confusion. Books and Other Individual Titles in Audiovisual Formats 715 When a division or other subsidiary part of a publisher appears in the publication, enter the publisher name first. Tokyo: Medikaru Rebyusha; 716 Citing Medicine Beijing (China): [Chinese Academy of Social Sciences, Population Research Institute]; Taiyuan (China): Shanxi ke xue ji she chu ban she; [Note that the concept of capitalization does not exist in Chinese. Designate the agency that issued the publication as the publisher and include distributor information as a note, preceded by Available from: ". For publications with joint or co-publishers, use the name given first as the publisher and include the name of the second as a note if desired. Box 40 No publisher can be found If no publisher can be found, use [publisher unknown] Kontrastdarstellung des Herzens und der grossen Gefasse im Rontgen-Kinofilm [Demonstration of the heart and large vessels in cine-radiographic film] [motion picture]. Audiovisuals with no place, publisher, or date of publication found 718 Citing Medicine Date of Publication for Books and Other Individual Titles in Audiovisual Formats (required) General Rules for Date of Publication Always give the year of publication Convert roman numerals to arabic numbers. Box 42 Non-English names for months Translate names of months into English Abbreviate them using the first three letters Capitalize them For example: mayo = May Books and Other Individual Titles in Audiovisual Formats 719 luty = Feb brezen = Mar Box 43 Seasons instead of months Translate names of seasons into English Capitalize them Do not abbreviate them For example: balvan = Summer outomno = Fall hiver = Winter pomlad = Spring Box 44 Date of publication and date of copyright Some publications have both a year of publication and a year of copyright. Box 45 No date of publication, but a date of copyright A copyright date is identified by the symbol, the letter "c", or the word copyright preceding the date.

In making clinical decisions whether a non-smoking firefighter has added risk similar to a cigarette-smoking non-fire fighter is a topic of great controversy and concern purchase zoloft 50 mg otc depression hotline chat. Diagnostic strategies based on probability of cancer and patient preferences are also similar and would include careful observation buy zoloft 25 mg visa anxiety over health, biopsy cheap zoloft 25mg otc depression symptoms emedicine, or proceeding directly to resection as described above discount 50 mg zoloft otc depression symptoms loss of interest. Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules. Self-Help for Tobacco Dependent Fire Fighters and Other First Responders By Matthew P. Like every chapter on health and disease, we will introduce the topic with information on why tobacco use is unhealthy and we will stress those issues that are of primary concern to fire fighters and other first responders. Most tobacco users already know the dangers and want to quit but have not been adequately informed that there are now modern quit methods with excellent success rates and minimal discomfort. This chapter will describe to you that program and how you and your health care professional can use this approach to become tobacco free. Tobacco smoke contains over 4,000 chemicals, 69 of which are known carcinogens, many more are known toxins. These chemicals are absorbed in the lungs and via the blood travel to virtually every organ, every tissue, and every cell in the human body. Tobacco can affect any part of the body but primarily and most directly affects the lungs and heart. The four major areas of tobacco s health effects on the human body involve cancers (and not just lung cancer), non-cancerous respiratory (lung) diseases, diseases of the heart and blood vessels and miscellaneous other effects. As dramatic as the effects of lung disease and cancer are, the greatest impact on morbidity and mortality is tobacco caused cardiovascular disease. The fact that the number one cause of fire fighter deaths is myocardial infarction (heart attacks) makes tobacco cessation a priority for fire fighters and other first responders. Anywhere from a third to half of all smokers die as a direct result of their tobacco use; many years sooner than if they didn t smoke. Many more become cardiac or respiratory cripples, eventually unable to do the simplest activities. These risks are even greater for fire fighters and other first responders who every day must depend on their own cardiopulmonary fitness and that of their coworkers. While every smoker knows tobacco kills, most are not aware of new methods, new medications and the combinations of medications available to help smokers (and other tobacco users) quit. If you are a smoker, odds are you have tried multiple times to quit and chances are great that you wish you were successful. Some reports show that the average smoker makes between six to nine serious attempts until they enjoy success and that over 70% of all smokers, wish they could quit. Indeed, if the negative effects of tobacco abstinence such as missing not smoking could be eliminated, the percentage of smokers wanting to quit would climb dramatically. Indeed, it is now possible to help smokers quit with virtually no pain and little, if any, discomfort. These successes are even more remarkable because they were obtained immediately after the devastating and traumatic effects of the terrorist attacks of 9/11. Self-Help for Tobacco Dependent Fire Fighters and other First-Responders human brain. Measuring Your Tobacco Addiction Karl Fagerstrm, a renowned Swedish tobacco addiction researcher over 20 years ago, designed a simple six question test to measure the severity of a smoker s nicotine addiction. The Fagerstrm Test for Nicotine Dependence has also been adapted for smokeless oral tobacco as well (Tables 4-4. Fagerstrm Test for Nicotine Dependence 10 or less 0 11 to 20 1 How many cigarettes per day do you usually smoke? Any other one 0 Do you smoke more frequently in the frst hours after No 0 waking than during the rest of the day? Yes 1 Scoring: 0-1 Very Low 2-3 Low 5-7 Moderate 7-8 High 9-10 Very High Table 4-4. For example, has a doctor told you that your health is being damaged by your smoking and yet, you continue to smoke? Even if smoking is not the direct cause of your illness, for most illnesses smoking is contributing to your continued deteriorating health and if despite knowing this you continue to smoke then your addiction is severe. Are you avoiding family members, friends or events because smoking is difficult or forbidden? Years ago, we had a smoking patient who refused to visit her grandchildren because her son-in-law forbade her smoking in the presence of the children. If you are avoiding significant people and events in your life so your smoking is undisturbed, your addiction is severe. If your workplace prohibits smoking and you are risking termination by smoking where it is forbidden, you are severely addicted. Self-Help for Tobacco Dependent Fire Fighters and other First-Responders 331 Modifed Fagerstrm Test for Smokeless Oral Tobacco Use After a normal sleeping period, do you use smokeless Yes 1 tobacco within 30 minutes of waking? No 0 Do you experience strong cravings for a dip or chew when Yes 1 you go for more than two hours without one? No 0 <9 0 On average, how many minutes do you keep a fresh dip or 10 - 19 1 chew in your mouth? Realizing that nicotine is such a strong addiction and that help is available is the first step to a conquering addiction and enjoying a lifetime of freedom from tobacco and improved physical fitness and health. The good news is modern day tobacco cessation therapies can not only minimize the discomfort that occurs when stopping but can also help you even if you are not ready to put down your cigarettes today. While the vast majority of all smokers want to stop, it is completely normal to have mixed feelings and experience aborted efforts and missteps. Quitting is a process and much can be learned from previous efforts even if you feel they were less than successful. Each attempt is a step towards success, especially if we can work together to determine the reasons for past missteps in the journey towards tobacco freedom and then construct a plan that tries to remove those barriers. For example, we recently saw a 30 cigarette-per-day fire fighter who had used a 21 mg transdermal nicotine patch and had reduced his cigarette consumption to seven cigarettes daily. During our evaluation, he reported a common response to this type of situation: The patch didn t work. Self-Help for Tobacco Dependent Fire Fighters and other First-Responders him that (to use firefighting language) the patch started to knock down his smoking addiction, it just did not go far enough. The 21 mg nicotine patch which delivers nicotine s-l-o-w-l-y through the skin (compared to smoking nicotine), was not designed to replace 100% of the inhaled nicotine from all the cigarettes for every smoker. Think about this: Elephants and mice like all mammals can develop bacterial upper respiratory infections. Does it make sense to fight a fire with the same number of fire fighters that has involved an entire city block as it does to knockdown a simple mattress fire? Similarly, why would we want to treat a 30 or 40 cigarette per day smoker the same as, say, a person who smokes five cigarettes per day? At this point you are probably wondering Isn t it unsafe to continue to smoke while using, say, the nicotine patch or gum? In fact, this a great way to help ambivalent or less than fully ready smokers to start on the road to better health as long as they make the commitment to eventually become tobacco free. Reduction to Cessation Treatments (Reduce then Quit) Let s say you smoke 25 cigarettes per day and want to cut-down but you re not ready to quit. Perhaps you refuse to quit now or maybe prior quit attempts failed due to severe cessation anxiety (the anxiety that occurs when contemplating quitting). Such patients can benefit from a reduction to cessation treatment approach where medication is started prior to quitting.

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