Avapro

Baha Al-Shaikh

• Consultant in Anaesthesia, Benenden Hospital, Kent
• Visiting Professor, Canterbury Christ Church University, UK

These disorders are multifactorial in origin diabete ou diabetes cheap avapro uk, with a complex interaction between genetic and environmental factors contributing to their development [1] diabetes university buy discount avapro 150mg. Accordingly definition of unstable diabetes cheap avapro 300mg fast delivery, comorbidity includes: 1) conditions directly pathophysiologically linked to the index disease diabetes mellitus gangrene buy avapro 300 mg with mastercard. Comorbidities are associated with increased use of multiple therapies and, therefore, higher risk of drug interactions. In multimorbidity, no index disease is defined and all morbidities are regarded of equal importance. Not surprisingly, greater healthcare utilisation accompanies this higher chronicity burden [6]. As a consequence, the impact of comorbid conditions in individuals suffering from these disorders has become a growing concern for healthcare providers. Early in life, the female/male ratio is 7/1 but this narrows to 2/1 after the fifth decade [12]. Moreover, older age at diagnosis is associated with a decreased survival, related to both disease severity and comorbid conditions, when compared to a population matched for age, sex and race [19, 21]. Notably, fever, lymphadenopathy, weight loss, arthralgia and fatigue (all common presenting symptoms) may also be due to other conditions more prevalent in the ageing population, such as endocrinopathy, infections or malignancy. While clinical manifestations generally do not differ significantly across age groups, elderly patients have higher rates of infections, malignancies and mortality [36]. In addition, older patients are more likely to have normal creatine kinase levels, which, together with the nonspecific presenting symptoms. Uncertainty remains, however, over how best to follow, treat and conduct research in this patient population. Initial evaluation should include a comprehensive clinical, functional and radiological assessment. Lymphocytic infiltration of the upper airway mucosa may cause hoarseness and persistent dry cough. In addition, up to 20% of patients have recurrent bronchial and pulmonary infection [112]. A combination of restrictive pulmonary disease, obstruction of the oropharyngeal airway due to temporomandibular joint involvement and compression of the medullary respiratory centres by cervical spinal joint arthritis are likely contributors to the development of this complication [140]. With cell division, telomeres tend to shorten, as the replication machinery does not copy fully to the ends. Telomere shortening is a feature of normal ageing but it is more pronounced in disease characterised by accelerated ageing, such as cardiovascular disease, pulmonary fibrosis and diabetes [145]. In addition to age and telomerase function, several exposures contribute to accelerated telomere shortening via increased oxidative stress and systemic inflammation [145]. Notably, telomeres are significantly longer in women than men after adjusting for age and smoking [153], but the reasons for this are not clear. The need for multiple hits would also explain why these diseases tend to manifest late in life [168]. Immunosuppressive treatments, however, are associated with significant adverse effects, including infection, a concern of particular relevance in elderly patients. Long-term prognosis remains poor and the loss in life expectancy is approximately 7 years in female and 5 years in male patients [199]. Similarly, the direct costs of treatment and the indirect costs of disability and lost productivity are substantial [200]. The overall comorbidity profile is similar to that observed in other autoimmune diseases [201] and this can be due to either toxicity of immunosuppressive therapies commonly used across autoimmune disorders or shared pathogenetic mechanisms. Renal impairment, sustained inflammation and corticosteroid use (both directly and by inducing a metabolic syndrome) are additional contributors to premature atherosclerosis and hypertension [212]. Secondary amyloidosis, cardiovascular complications and fractures are the main contributors to the excess mortality observed in this patient population [226, 227]. Disease-related complications, long-term treatment-related adverse events and associated comorbidities are major contributors to the significant mortality and morbidity associated with these conditions. In fact, while in principle, therapeutic strategies should not differ substantially from that recommended in younger patients, treatment of elderly patients is often complicated by comorbidities, increased rate of treatment-related adverse events and polymedication. Yet, due to the lack of specifically designed evidence-based guidelines for management, this patient subgroup is often either undertreated (by virtue of its inherent frailty) or inadequately managed despite the availability of effective and well-tolerated drugs. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Defining populations at risk of rheumatoid arthritis: the first steps to prevention. The global burden of rheumatoid arthritis: estimates from the Global Burden of Disease 2010 study. The influence of ageing on the development and management of rheumatoid arthritis. Emerging cellular and molecular targets in fibrosis: implications for scleroderma pathogenesis and targeted therapy. Mortality in systemic sclerosis: an international meta-analysis of individual patient data. The three-year incidence of pulmonary arterial hypertension associated with systemic sclerosis in a multicenter nationwide longitudinal study in France. Morbidity and mortality of patients diagnosed with systemic sclerosis after the age of 75: a nested case-control study. Comparison with adult and young onset of the disease in a cohort of 336 Italian patients. Late-onset systemic lupus erythematosus: a personal series of 47 patients and pooled analysis of 714 cases in the literature. Factors predicting malignancy in patients with polymyositis and dermatomyostis: a systematic review and meta-analysis. Systemic autoimmune diseases in elderly patients: atypical presentation and association with neoplasia. Features of polymyositis and dermatomyositis in the elderly: a case-control study. Antibodies against distinct nuclear matrix proteins are characteristic for mixed connective tissue disease. The prevalence and incidence of mixed connective tissue disease: a national multicentre survey of Norwegian patients. Late-onset ankylosing spondylitis and related spondylarthropathies: clinical and radiological characteristics and pharmacological treatment options. Late onset spondylarthropathy: clinical and biological comparison with early onset patients. Undifferentiated connective tissue disease: analysis of 83 patients with a minimum follow-up of 5 years.

Examining the patient comprehensively and accurately exercising good judgement in the selection of examination techniques Attitude the trainee a) diabetes mellitus gestasional buy 150 mg avapro free shipping. Diagnostic features of the range of disabling disorders including the clinical features of common cognitive deficits rimadyl and diabetes in dogs generic 150 mg avapro fast delivery, including attention ppg diabetes definition cheap avapro 150 mg amex, executive function diabetes mellitus signs and symptoms avapro 150mg with amex, memory, language, and spatial disorders, including the common patterns of these disorders and the behavioural consequences of these deficits b). A knowledge of the anatomy and surface landmarks of major joints and soft tissue structures c). Range of behaviours seen in patients with brain injury both in the acute, post acute and long term d). Prognosis and prognostic features of the range of disabling disorders e) Mechanisms of recovery, neural plasticity, learning and skill acquisition f) Influence of psychological factors Skills the trainee consistently takes a history and examines effectively by: 69 a). Providing information about the nature of investigations and further assessment to the patient. Attitude the trainee works to adapt their communication style to the needs of the patient 17. Non-pharmacological treatment options for disabling disorders include role of surgery, education, self management, occupational therapy, physiotherapy, exercise and rest, safe injection techniques, biomechanical modalities such as prosthetics, orthotics and splinting, assistive devices and environmental adaptation c). Long term management approaches for specific impairments including spasticity, respiratory failure and need for long term ventilation, pain, pressure sores e). Different treatment options and resources; both drug and non-drug, available for such psychiatric disorders, and cognitive deficits (including post traumatic amnesia) f). Benefits and limitations of counselling approaches g) Common approaches used to manage abnormal behaviours h) Provisions of the Mental Health Act Skills the trainee is able to a). Providing information about the nature of investigations and further assessment to the patient e). Reviews the results of investigations, interprets and records the results, acts upon and imparts them to the individual in a timely fashion including interpreting cognitive assessments and explaining their implications for the rehabilitation process, the patients and their family f) Keeps accurate, legible and complete records and comply with all the relevant legal, professional and organisational requirements and guidelines 72 Attitude the trainee a). Skills the trainee is able to consistently and safely a) provide accurate advice to patients and colleagues about their rights and responsibilities with regard to person with a disability and their carers Attitude the trainee consistently a) shows respect for the law b) acts within the law at all times c) demonstrates a positive attitude to decision making within a legal framework and is prepared to seek advice when necessary 17. Skills the trainee is able to consistently and safely a) design and write a comprehensive study protocol using standard headings b) complete ethics and trust R&D forms if necessary c) recruit, and consent study subjects d) collect data and store it appropriately e) analyse data appropriately f) prepare written and verbal reports g) explain implications for practice and steps required to incorporate any changes deemed necessary as a result of the study Attitude the trainee consistently a) recognises the importance of, and displays enthusiasm towards, the advancement of research within rehabilitation b) is supportive of the research efforts of others c) is realistic about the benefits and challenges of rehabilitation research and is usually supportive of research within his/her area of work the trainee is able to present research/audit study results orally and in written form Knowledge the trainee consistently demonstrates a knowledge of a) use of word processing packages b) use of PowerPoint to produce slides and posters Skills the trainee is able to consistently and safely a). Attitude the trainee consistently a) is aware of the importance of reporting audit and research findings and is committed to doing so b) is supportive of others who are reporting audit and research findings 17. Observation by trainer b) multisource feedback c) Inspection of notes, letters, summaries and treatment plans. The aetiology and epidemiology of upper and lower limb amputation congenital and acquired. The epidemiology, aetiology and clinical significance of peripheral vascular disease and available methods of investigation and management. Biomechanical principles of artificial limbs, their components and methods of fabrication. Indications and contraindications for prosthetic and on prosthetic management of amputation. Adopts a sympathetic and empathetic attitude towards parents with a child with limb deficiencies. Observation by trainer b) Case based discussion c) Inspection of notes, summaries and treatment plans. The total early management following injury (including an understanding of physiotherapeutic modalities in respiratory care) e). Bladder management and care of the acutely paralysed bladder and long term care of the urinary tract. Management of the following aspects of general rehabilitation and neurological rehabilitation with particular reference to spinal injury: o Pressure management and tissue viability assessment; o Sexual function and male fertility o Pain management techniques o Wheelchair assessment, specialised seating and orthotics prescription o the technique and application of psychometric testing. Manage the seriously ill, including people with cardiac dysfunction or respiratory failure requiring assisted ventilation. Manage autonomic dysreflexia and orthostatic hypo/hypertension Attitude the trainee consistently a). Adopts a non-discriminatory attitude to all patients and recognise their needs as individuals. Epidemiology, aetiology and pathology of diseases of bones and joints including trauma. Orthopaedic management of people who have sustained fractures, including those with multiple trauma and non-orthopaedic injuries. The role of orthopaedic surgery in children and adults in the areas of scoliosis and cerebral palsy management. The principles of surgical management of degenerative joint disease with particular reference to arthroplasty. Musculoskeletal pain associated with changes in bones, joints, ligamentous and other soft tissues. Disability arising as a result of other pathology of the connective tissues, including deformities and contractures. Indications for medical, surgical, orthotic, paramedical, behavioural and other forms of therapy for this group of people. Appropriate use of paramedical, orthotic and other therapies in this group of conditions. Appropriate pain management techniques complementary to those learnt in a pain management attachment and relevant to orthopaedic practice. Assessment and management of disability resulting from trauma and musculoskeletal 90 disease, congenital and acquired. Assessment and appropriate management of people with brachial plexus and peripheral nerve lesions. Diagnosis and management of musculoskeletal disease, including back and neck pain, soft tissue rheumatism and multiple trauma. Appreciation of patients discomfort during examination and ability to take remedial action. Clinical pain patterns and their diagnostic associations including neurogenic, mechanical, inflammatory as well as common pain syndromes. Techniques for measuring pain and its impact on the lives of people with manifest disability. The assessment of the relative importance of organic and non-organic factors in the expression of pain. The social consequences of chronic pain for the individual and his/her family and carers, including the impact on employment and education, social security benefits, finance and demands on health and social service. The appropriate investigation of people with chronic pain utilising clinical, radiological psychological, and questionnaire techniques. Pain self management & Chronic back pain programmes:patient assessments & selection, goal planning, outcome measures. Appreciate the range of psychological reactions to chronic pain, including the way in which secondary gain may be influenced by personal, family and societal factors. Identifying the presence of illness behaviour and other maladaptive phenomena within the constellation of symptoms associated with chronic pain. Identifying modifiable cognitive and behavioural factors influencing disability. Assessing the severity of symptomatology in the light of investigations of cardiac, psychological and social status. Application of medical, surgical, behavioural, dietary and family therapy in the management of a person with heart disease. Recognition of non-organic symptomatology and behaviour in people who have cardiac disease or present with cardiac symptomatology. The assessment and rehabilitation of people with heart disease, including people who have had cardiac surgery.

The ability to make appropriate diagnostic and management decisions that have important consequences for patients will be assessed managing diabetes without insulin safe 300 mg avapro. Exam content Exam content is determined by a pre-established blueprint diabetic jewish diet cheap 150mg avapro, or table of specifications diabetes type 1 4 year old order 150mg avapro amex. The primary medical content categories of the blueprint are shown below diabetes insipidus cats purchase generic avapro on-line, with the percentage assigned to each for a typical exam: Medical Content Category % of Exam Allergy and Immunology 2% Cardiovascular Disease 14% Dermatology 3% Endocrinology, Diabetes, and Metabolism 9% Gastroenterology 9% Geriatric Syndromes 3% Hematology 6% Infectious Disease 9% Nephrology and Urology 6% Neurology 4% Obstetrics and Gynecology 3% Medical Oncology 6% Ophthalmology 1% Otolaryngology and Dental Medicine 1% Psychiatry 4% Pulmonary Disease 9% Rheumatology and Orthopedics 9% Miscellaneous 2% Total 100% Every question in the exam will fall into one of the primary medical content categories shown above. Questions ask about the work done (that is, tasks performed) by physicians in the course of practice: Making a diagnosis Ordering and interpreting results of tests Recommending treatment or other patient care Assessing risk, determining prognosis, and applying principles from epidemiologic studies Understanding the underlying pathophysiology of disease and basic science knowledge applicable to patient care Clinical information presented may include patient photographs, radiographs, electrocardiograms, recordings of heart or lung sounds, and other media to illustrate relevant patient findings. Rational: Does the intervention meet the test of competent assessment (diagnosis) and scientifically proven benefit Are known risks and iatrogenic complications weighed against anticipated benefits This cutout Bearing Knees are posterior stabilized 4-in-1 Instruments accommodates the extensor mechanism prostheses designed to accommodate Multi-Reference 4-in-1 Instruments are in deep flexion. For provide a choice of either anterior or example, the interaction of the posterior Additionally, the cam/spine mechanism posterior referencing techniques for condyles on the articular surface was has been modified to provide greater making the femoral finishing cuts. As a result, efforts have jump height as the knee prosthesis the anterior referencing technique been made to optimize the contact area undergoes deep flexion between 120 uses the anterior cortex to set the as the posterior condyles roll back to and 155. Bearing Knee Components can be implanted using any of the NexGen the instruments and technique assist the surgeon in restoring the center Knee Instrument Systems. Use the template decision of fixed or mobile can be made overlay (available through your Zimmer intraoperatively. This angle femoral component, the gold Femoral should be reproduced intraoperatively. Patients it is suggested that the patient criteria with good flexion preoperatively tend include non-obese patients with to get better motion postoperatively. This need may be dictated by cultural or social See the back section of the surgical customs where practices such as technique for package insert. Also, activities specific to daily living, leisure and recreation, or job performance may require high-flexion capability. E/4-6 F/5-7 G/6-8 6 Use the various templates to 7 F/5-7 G/6-8 approximate the appropriate component 8 G/6-8 sizes. Verify that the femoral and tibial component sizes approximated will be compatible by cross-referencing Preoperative Conditioning the femoral and tibial sizes on the Interchangeability Chart. To prepare the patient for surgery, it may be helpful for the patient to Note: If a femoral/tibial mismatch perform mobility exercises to prepare exists, a fixed bearing system the ligaments and muscles for the should be used. Close attention minimize tension in the remaining must be paid to balancing the flexion quadriceps below the level of the and extension gaps, clearing posterior tourniquet. It is imperative that the osteophytes, releasing the posterior muscle relaxant be injected prior to capsule, and reproducing the joint line. Alternatively, spinal or epidural anesthesia should Although the joint line often changes produce adequate muscle relaxation. The alteration of the joint line can be minimized by accurately measuring for the femoral component size and performing a posterior capsulotomy to correct flexion contractures. The surgeon can pole of the patella, and extend it 1cm of peritenon and capsule medial to choose a midvastus approach, a subvas approximately 10cm to the level of the patellar tendon. This is important to tus approach, or a medial parapatellar the superior patellar tendon insertion facilitate complete capsular closure. Also, depending on surgeon at the center of the tibial tubercle Split the superficial enveloping fascia of preference, the patella can be either (Fig. Be careful to avoid disruption of the quadriceps muscle percutaneously everted or subluxed. This will facilitate in a proximal direction over a length of the length of the incision is dependent access to the vastus medialis obliquus, approximately 6cm. This will mobilize the on the size of the femoral component and allow a minimal split of the muscle. Although the goal of a minimally It will also improve visualization of the greater lateral translation of the muscle invasive technique is to complete the lateral aspect of the joint obliquely. The while minimizing tension on the patellar surgery with an approximately 10cm length of the incision should be about tendon insertion. If the incision must distributed evenly relative to the joint be extended, it is advisable to extend line, it is preferable that the greater it gradually and only to the portion be distal. Be careful to the arthrotomy through a midvastus avoid disrupting the extensor insertion. Once As this procedure becomes more the patella is everted, use a standard familiar, the level of the midvastus size Hohmann retractor or two small incision should be lowered to maintain Hohmann retractors along the lateral Fig. The oblique portion of the Note: It is imperative to maintain close degree of varus or valgus deformity. For valgus deformities, consider key aspect of the subvastus approach performing a more conservative medial is that it is not necessary to evert the Remove any large patellar osteophytes. This helps avoid tearing of the Release the anterior cruciate ligament, already attenuated tissue complex. This release allows the patella the border of the retinaculum/tendon to to retract laterally. Check for symmetry and balance Minimally invasive total knee of the flexion and extension gaps. Begin by making a 10cm-14cm midline skin incision from the superior aspect of the tibial tubercle to the superior border Fig. Following subcutaneous dissection, develop medial and lateral flaps, and dissect proximally and distally to expose the extensor mechanism. This permits mobilization of the skin and subcutaneous tissue as needed during the procedure. In addition, with the knee in flexion, the incision will stretch 2cm-4cm due to the elasticity of the skin, allowing broader exposure. The goal of minimally invasive surgery is to limit the surgical dissection without compromising the procedure. The medial parapatellar arthrotomy is used to expose the joint, but the proximal division of the quadriceps tendon should be limited to a length that permits only lateral subluxation of the patella without eversion (Fig. If there is difficulty displacing the patella laterally or if the patellar tendon is at risk of tearing, extend the arthrotomy proximally along the quadriceps tendon until adequate exposure is achieved. The basic medial structures until they reach principle for ligament release entails the length of the lateral supporting that the tight contracted concave side structures. To facilitate the release, excise osteophytes from the medial femur and With the Flexion Balancing Instruments, tibia. These osteophytes tent the medial the flexion gap is addressed first capsule and ligamentous structures, (Reference Appendix A, page 39). In and their removal can produce a flexion the medial and lateral soft tissues minimal correction before beginning as well as the posterior joint capsule the soft tissue release. This osteophytes may need to be removed procedure helps minimize the need for after the proximal tibia is resected. After accessing the knee joint, balancing Lax Tensed of the soft tissue structures and removal of osteophytes is initiated. Posteromedial osteophytes may need to be removed after the proximal tibia is Contracture resected. Though lateral osteophytes the Extramedullary/Intramedullary and insertion of the pes anserinus may be present and should be removed, Tibial Resector provides a choice of tendons. Continue the elevation with a they do not bowstring the lateral techniques for tibial resection. Each periosteal elevator to free the posterior collateral ligament in the same way as of the techniques offers a number of fibers.

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Historians these days tend to distrust the idea that the actions of specific people truly cause large-scale change blood sugar 90 after eating buy avapro with a mastercard. Rather diabetes diet menu in hindi cheap avapro online mastercard, many argue diabetes quotes avapro 150 mg visa, change more commonly results from a complex interplay of cultural and political factors diabetes type 1 diet plan order generic avapro on line. To be sure, it took the social changes of the 1960s and 1970s to make graduate medical education susceptible to reform from the outside. But Sidney Zion sped things up considerably, ensuring that Libby had not died in vain. In presenting its case, the hospital introduced a claim, unsupported by toxicology testing and vigorously disputed by the plaintiffs, that Libby Zion had died as a result of cocaine ingestion that she had concealed from her doctors. Indeed, it is quite possible that without this rage, he might not have accomplished what he did. According to the National Volunteer Fire Council, each of those categories is approximately 73 percent of the 1. For example, fire fighters include individuals assigned to engines, trucks and special response units; those with paramedic training; and officers and employees assigned to the Fire Inspector office, training division and other specialized units. Superimposed on the variability in job descriptions are the unique characteristics of different fire departments/bureaus/districts and stations within those organizations. The effects of their long work hours relate to physical exhaustion, in addition to sleep loss. We and others have documented that fire fighters are a high-risk group, with an increased prevalence of obesity, hypertension, high cholesterol levels, certain malignancies and chronic musculoskeletal complaints (Elliot et al. Much less data are available on work-related morbidity and mortality for other groups of first Management strategies have been responders. Among all occupations, the highest risk developed to minimize the adverse health of cardiovascular disease is with law enforcement consequences of the sleep loss and officers (Calvert, Merling & Burnett, 1999), whose circadian disruption of shift work and life expectancies are 15 years less than the average extended work hours. In general, they are employed for pre-hospital care by private companies, public municipalities and hospitals. When assessing the effects of long work hours, many other variables must be considered. Specifics of the job description, work structure and its context and characteristics of the individual employee all may affect outcomes. Accordingly, those issues must be taken into account when generalizing study findings and applying any conclusions to other settings. As a result, in presenting information, we have tried to provide specifics concerning the study group and methodology when describing information. The National Fire Fighter Near-Miss Reporting System is a voluntary, non-punitive means to capture and learn from incidents and near-incidents, and its 2006 summary report provides a convenience sample of the many different shift structures of fire fighters (Figure 4. Among reports submitted to the Near-Miss Reporting System, 12 percent indicated that their department had 2 shifts (days and nights) of 10 to 14 hours length. The majority of reports were from departments using three platoons or shifts deployed in rotations. Thirty percent reported 24 on/48-off formats, and 23 percent indicated alternative 24 hour rotations. The latter usually is an on-off-on-off-on then 4 off schedule (depending on nuances, called 3/4, modified Detroit or modified Berkeley). More than 19 variations on those basic three platoon rotation patterns are in use. Most departments have a Kelly or off day every 8th shift to reduce the number of hours worked from becoming overtime. Some departments maintain a fourth smaller platoon to staff Kelly days and leaves. The result is a work week that for most fire fighters averages 48 to 56 hours, not counting overtime. In the last few years, a 48 hours on and 96 hours off schedule has become more popular. In the Near-Miss reports, 3 percent of departments listed the newer 48-on/96-off schedule. The format originated in Southern California, because fire fighters were unable to afford local housing and faced long commutes, which were reduced in half with that schedule. Because it represents a new work format, descriptive information is available from departments adopting that schedule, which is summarized in Section 4. Distribution of Work Schedules in 2006 Near-Miss Accident Reports* *The Near-Miss Reporting System is a convenience sample and may under represent volun teer fire fighters. Only approximately one-third of reports are from volunteer departments, when nationwide volunteer departments represent 71 percent of fire departments. For example, a staffing pattern might be 12 hour shifts, with a maximum of three in a row, with a guarantee of 48 hours per week and an attempt to provide employees 60 hours each week. The staffing patterns are complex, and web-services are available to aid in meeting those demands, such as Among those workers, because of helicopters and fixed-wing craft pilot regulations, which limit work hours, staffing patterns for pilots and medical personnel differ; pilots generally work 10 to 14 hour shifts, while the medical teams are approximately equally divided as working either 10 to 12 hour shifts or 24 hour schedules. There is scheduling diversity among air medical transport work sites, depending on work load, whether privately operated or hospital-based and other factors (Frakes & Kelly, 2004). In general, fire fighters have an established tradition of working 24 hour shifts, and few complaints are registered about that pattern. Those who question the wisdom of that scheduling format, on the grounds of either safety or economics (Philpot, 2005), have received harsh criticism from fire fighters submitting comments (Firehouse Forum, 2003). Pertinent issues included responding to events when on duty for more than 15 hours, driving home from busy 24 hour shifts and fatigue when awoken for early morning calls. The near-miss records have a place for incident time, but summary reports indicate that for most submissions, that information is not included, and specifics concerning the relationship between time of day and near-misses is not available. Brian Gould, a 42-year-old paramedic, died when driving home from an overnight shift when his car crossed lanes and struck a semi head-on. Because of the incident, the ambulance service, which previously had moved from 24 to 12 hour shifts due to paramedic fatigue issues, instituted a policy that if a crew gets less than four hours of uninterrupted sleep during a 24 hour shift, colleagues were to take them and their vehicles home after work (Erich, 2007). With restructuring from 24 hour shifts to 48-on/96-off formats, departments have done assessments of that change, and findings have been posted to the internet to assist other departments considering making similar changes. In general, fire fighters, their union, management and budgetary officials have collaborated on designing the new format, with all agreeing on a specific trial plan. Calls per station varied from approximately 3500 calls (busiest) to 300 calls (least busy) per year. They found that the fire fighters slept more while on shift with the 48 hour format. When not at work, hours Additional information slept also increased after the change; individuals reported an average from fire fighter fatality, of 7. Making the change did not incident/death reporting appear to adversely impact citizen complaints, damage reports, turnout systems is included in times, injuries or overall vehicle accidents. Sick leave decreased with the longer format, which also was reflected in decreased need for overtime. The majority of fire fighters and their families liked the 48-on/ 96-off schedule. Fire fighters felt that it interfered significantly less with family, leisure and social activities. Findings long hours with disasters or other from an internet survey of citizen feedback were positive unforeseen occurrences.