Outpatient Treatment

Programs with outpatient treatment vary in the types and intensity of services offered. Outpatient treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social support. Sometimes less intense recovery programs offer little more than simple drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual characteristics and needs of the patient. Group counseling is a major component in many outpatient programs. Some outpatient programs treat patients with medical or other mental health problems in addition to drug disorders.

FDA Medical Device Registration

Owners or operators of places of business that are involved in the production and distribution of medical devices intended for use in the United States must register annually with the FDA, which is a process known as establishment registration. Congress has authorized FDA to collect an annual establishment registration fee for device establishment registrations. A detailed list of all those establishment types that have to pay the registration fee is available at "Who Must Register, List and Pay the Fee." There are no reductions in annual establishment registration fees for small businesses or any other group. Most establishments that are required to register with the FDA are also required to list the devices made there and the functions of those devices. If a device requires pre-market approval or notification before marketed in the U.S., then the owner/operator should also submit the FDA pre-market submission number. The amendments to the Medical Device User Fee Modernization Act require that after September 30, 2007, all businesses submit registration and listing information electronically. Registration and listing provides the FDA with the location of medical device establishments and the devices manufactured at those establishments. This information augments the ability of the United States to prepare for and respond to public health emergencies.

Adjustable Gastric Band

A laparoscopic adjustable gastric band, commonly referred to as a lap band, is an inflatable silicone device that a surgeon places around the top portion of the stomach, via laparoscopic surgery, in order to treat obesity. Adjustable gastric band surgery is an example of bariatric surgery designed for obese patients with a body mass index (BMI) of 40 or greater, or between 35 to 40 in cases of patients with certain co-morbidities that are known to improve with weight loss, such as sleep apnea, diabetes, osteoarthritis, high blood pressure or metabolic syndrome, among others. Gastric banding is the least invasive surgery of all bariatric surgeries. Gastric banding using laparoscopic surgery usually results in a shorter hospital stay, faster recovery, smaller scars, and less pain than open surgical procedures. The patient can continue to absorb nutrients from food normally. Gastric bands are made entirely of biocompatible materials, so they can stay in the body without causing harm. However, not all patients are eligible for laparoscopy. Patients who are extremely obese, who have had previous abdominal surgery or have complicating medical problems may require a more open surgery approach. The surgeon creates a small incision near the belly button and pumps carbon dioxide into the abdomen to create a workspace. Then the surgeon inserts a small laparoscopic camera through the incision into the abdomen. The camera sends a picture of the stomach and abdominal cavity to a video monitor. It gives the surgeon a good view of the key structures in the abdominal cavity. The surgeon makes more small incisions in the abdomen. The surgeon watches the video monitor and works through these small incisions using instruments with long handles to complete the procedure. The surgeon creates a small, circular tunnel behind the stomach, inserts the gastric band through the tunnel and locks the band around the stomach. Clinical studies of laparoscopic bariatric surgery patients found that they felt better, spent more time doing recreational and physical activities, benefited from enhanced productivity and economic opportunities and had more self-confidence than they did before surgery. The placement of the band creates a small pouch, or stoma, at the top of the stomach. This pouch holds approximately one half cup of food. A typical stomach holds about six cups of food. The pouch fills with food quickly, and the band slows the passage of food from the pouch to the lower part of the stomach, causing the sensation of being full. As the upper part of the stomach registers as full, the message to the brain is that the entire stomach is full, and this sensation helps a person to be hungry less often, feel full more quickly and for a longer period, eat smaller portions, and lose weight over time. As patients lose weight, their bands will need adjustments, or "fills," to ensure comfort and effectiveness. The surgeon can adjust the gastric band by introducing a saline solution into a small access port just under the skin. There are many port designs and a surgeon may place them in varying positions, but they always connect to the muscle wall in and around the diaphragm via sutures or staples.

What Makes People Sleep?

Although people may put off going to sleep in order to squeeze more activities into the day, eventually the need for sleep becomes overwhelming and people must get some sleep. This daily drive for sleep appears to be due, in part, to a compound known as adenosine. This natural chemical builds up in the blood as time awake increases. While people sleep, the body breaks down the adenosine. Thus, this molecule may be what the body uses to keep track of lost sleep and to trigger sleep when needed. An accumulation of adenosine and other factors might explain why, after several nights of less than optimal amounts of sleep, people build up a sleep debt that people must make up for by sleeping longer than normal. Because of such built-in molecular feedback, people cannot adapt to getting less sleep than the body needs. Eventually, a lack of sleep catches up with everyone.
The internal "biological clock" and environmental cues govern time of day when people feel sleepy and go to sleep. The most important cues are light and darkness. The biological clock is actually a tiny bundle of cells in the brain that responds to light signals received through the eyes. When darkness falls, the biological clock triggers the production of the hormone melatonin. This hormone makes people feel drowsy as it continues to increase during the night. Because of the biological clock, people naturally feel the sleepiest between midnight and 7 AM. People may also feel a second and milder daily "low" in the mid-afternoon between 1 PM and 4 PM. At that time, melatonin production rises again and might make people feel sleepy.
The biological clock makes people the most alert during daylight hours and the drowsiest in the early morning hours. Consequently, most people do very good work during the day. In a 24/7 society, however, some people must work at night. Nearly one-quarter of all workers work shifts that are not during the daytime and more than two-thirds of these workers have problems with sleepiness and/or difficulty sleeping. Because some work schedules are at odds with powerful sleep-regulating cues like sunlight, night shift workers are often drowsy at work and have difficulty falling or staying asleep during the daylight hours.
The fatigue experienced by night shift workers can be dangerous. Major industrial accidents--such as the Three Mile Island and Chernobyl nuclear power plant accidents and the Exxon Valdez oil spill--are results of mistakes made by overly tired workers on the night shift or an extended shift.
Night shift workers also are at greater risk of being in car crashes when driving home from work. One study found that one-fifth of night shift workers had a car crash or a near miss in the preced­ing year because of sleepiness on the drive home from work. Night shift workers are also more likely to have physical problems, such as heart disease, digestive disturbances and infertility, as well as emo­tional problems. All of these problems can relate to the workers' chronic sleepiness. See "Working the Night Shift" for some helpful tips.
Other factors can also influence the need for sleep, including the production of cellular hormones called cytokines by the immune system. These compounds occur in large quantities in response to certain infectious diseases or chronic inflammation and may prompt a person to sleep more than usual. The extra sleep may help the person conserve the resources needed to fight the infection. Recent studies confirm that people who rest enough are improving the ability of the body to respond to infection.
People are creatures of habit and one of the hardest habits to break is the natural wake and sleep cycle. A number of physiological factors conspire to help people sleep and wake up at the same times each day. Consequently, people may have a hard time adjusting when traveling across time zones. The light cues outside and the clocks in a new location may suggest it is 8 AM and to should be active, but the body believes it is more like 4 AM and to should sleep. The result is jet lag--sleepiness during the day, difficulty falling or staying asleep at night, poor concentration, confusion, nausea and general malaise and irritability.