BACKGROUND : Although the GOLD guidelines have raised the level of awareness of COPD in physicians, there are still several lacunae in the implementation of these evidence based guidelines into actual clinical practice
AIM : The Rationale was to review the management of COPD patients at our tertiary care urban teaching hospital several years after introduction of GOLD guidelines.
METHODS : Retrospective analysis of medical records of our patients admitted over one year period with the diagnosis of COPD from June 2005 to July 2006
RESULTS : There were 150 subjects with a discharge diagnosis of COPD mean age 64.5 yrs; there were 114(76%) males and 36(24%) females . Diagnosis of COPD was missed on admission in emergency department in 20 patients (13%). 125 patients (85% ) were treated with steroids, nebulized therapy, antibiotics & oxygen supplementation, although only 60% fulfilled the GOLD criteria for acute exacerbation. Thus 25% of patients (n=62) were wrongly labelled as acute exacerbation of COPD. 200 patients (86%) had normal chest x-rays. 114 patients (76%) were current or ex-smokers. Smoking history was not obtained in 10% (n=25)of cases. Arterial blood gases were done in 110 patients (73%) follow-up ABGs were done in only 30% of cases (n=45 ). 37 patients (25% ) required ICU care & 15 (10%) required non invasive ventilation. Average LOS in ICU was 3.2 days and in the hospital was 8.4 days. Upon discharge, smoking cessation counselling was offered in only15 cases(10%) & only 1% were referred for chest physio & pulmonary rehabilitation programme. Inhaled long acting Beta-2 agonists &/or inhaled long acting anti cholinergic agent (tiotropium) was prescribed in only 90 patients (60%); advice on annual influenza vaccination was offered in only 67 patients (45%).
CONCLUSIONS : Despite the availability of GOLD guidelines for several years
(a) physicians at our center have problems in accurately diagnosing COPD exacerbation (b) Over diagnosis is not uncommon (c) smoking history was not elicited in all patients (d) serial monitoring by ABGs was not uniformly done (e) Patient education & counseling by discharge physicians was inappropriate & lacked commitment
Tuesday, August 17, 2010
PORTABLE MONITORING OF OBSTRUCTIVE SLEEP APNOEA
The controversy about streamlined diagnosis & treatment of obstructive sleep apnoea has been raging on for more than one and a half decade. Opponents of portable monitoring demand more and better proof that indeed portable monitoring is reliable despite the excellent results with this technology in earlier two studies – Cleveland family study (1) & the sleep heart heath study(2).
Several critics argue that the diagnosis of obstructive sleep apnoea outside a sleep lab will only be cost effective if autotitrating positive airway pressure (APAP) “works”. A recent meta analysis of nine randomized trials comprising of 282 patients showed that APAP and standard CPAP were similar in adherence and equally effective(3).
The cost difference between APAP and in-lab CPAP titration is huge & favours routine APAP in those with high index of clinical suspicion for OSA in the present era of cost cuttings.
Sleep medicine continues to evolve rapidly. The current emphasis is on expedited diagnosis & management of OSA. In several parts of Europe & recently in North America it is now an acceptable practice to use portable monitoring device for determining which patients are eligible for CPAP treatment. New information about CPAP application seems likely to demystify and probably eliminate routine use of in-lab CPAP titrations. However the American Academy of Sleep Medicine continues to oppose the use of portable monitoring in diagnosis of OSA (4,5).
Recently, a multi centre study comparing unsupervised polysomnography (PSG) in patient’s home with PSG supervised at an academic sleep centre showed effectively that portable monitoring is a better predictor of morbidity & mortality than in-lab PSG (6). Similarly another study by Japanese authors showed that simple nocturnal oximetry can be a “valid tool” in selected subgroup of patients when the pretest probability is high as shown by them in obese patients (7). The clinical value of performing full night 16 channel PSG on patients with possible OSA has been questioned by several authors. Douglas et al(8) prospectively analysed sleep data of 200 patients to determine which signals contributed to diagnostic accuracy. Respiratory variables & leg movement sensors were helpful, whereas neuro physiological signals did not contribute significantly to the diagnosis. There is therefore an increasing tendency to use less complicated diagnostic techniques to confirm the diagnosis of OSA. These limited home studies measure more than single channel of oximetry & mostly include respiratory signals. Commonly measured combinations are oximetry, airflow, thoraco abdominal movements & heart rate measurement. There are several new portable devices in the market & this field is changing rapidly (9,10). Many of these portable devices can be conveniently used in patient’s home after adequate instructions. Studies performed in this way can be cost effective, convenient & accurate. However there are several problems with portable devices such as equipment failure, night to night reproducibility & reliability(11). The sensitivity ranges from 32% to 100% & specificity from 33% to 100% compared with full PSG in a sleep centre (12).
A review article published by American academy of sleep medicine gives a classification system for portable monitors based upon the number & type of parameters recorded by each machine(13). Further details about this classification system shall be discussed in my talk & its utility shall be highlighted. It is of paramount importance to understand that clinicians caring for patients with sleep disorders should be familiar with all the limitations associated with any individual sleep monitoring device, particularly if the potential diagnosis of sleep apnoea is refuted. It is equally important to appreciate that the specific technology used for making the diagnosis is less important than the level of experience & training available for interpreting the results.
REFERENCES :
1. Redhine S, Tosteson T, Boucher MA et al. Measurement of sleep related breathing disturbances in epidemiologic studies: Assessment of validity & reproducibility of a portable monitoring device. Chest 1991;100:1281-86
2. Quan SF & the Sleep Heart Health Study (SHHS) Research group; short term variability of respiration & sleep during unattended non laboratory polysomonography. The Sleep Heart Health Study. Sleep 2002;2:843-849.
3. Ayar NT, Patel SR, Malhotra A et al. Auto titrating versus standard CPAP for treatment of OSA results of meta analysis. Sleep 2004;27:249-53.
4. Chesson AL, Berry RB, Pack AP. Practice parameters for use of portable monitoring devices in investigation of suspected OSA in adults. Sleep 2003;26:907-913.
5. Position statement of American Academy of J.Clin.Sleep Med.2006;2:274
6. Iber C, Redhine S, Kaplan Gilpin AM et al. Polysomnography performed in the unattended home versus the attended laboratory setting – Sleep Heart Health Study Methodology. Sleep 2004;27:536-40.
7. Nakano H, Ikeda T, Hayashi M et al. Effect of Body Mass Index on overnight oximetry for diagnosis of obstructive sleep apnoea. Respir Med.2004;98:421-27.
8. Douglas NJ, Thomas S, Jan MA clinical value of polysomnography. Lancet 1992; 339;347-50.
9. Whittle AT, Finch SP, Mortimer IL, Machay TW & Douglas NT use of home sleep studies for diagnosis of sleep apnoea / hypopnoea syndrome. Thorax 1997;52:1968-73.
10. Rees K, Wraith PK, Besthon Jones M & Douglas NJ. Detection of apnoea, hypopnoea & arousals by the Auto set in sleep apnoea/ hypopnoea syndrome Eur. Respir J. 1998;12:76-9.
11. American Academy of Sleep Medicine, American College of Chest Physicians & American Thoracic Society, Evidence review on Home diagnosis of sleep apnoea: a systematic review of literature Chest 2003;124:1543-79.
12. Ross SD, Allan IE, Harrison KJ et al. Systematic review of literature regarding diagnosis of sleep apnoea. Rockville, MD: Agency for Health care policy & Research 1999.
13. Li CK, Ward Flemons W. State of home sleep studies. Clin.Chest Med.2003;24(2):283-95.
FURTHER READING:
1. Douglas NJ Home diagnosis of obstructive sleep apnoea. Sleep Med.Rev.2003;7(1)53-9.
2. Davidson TM, Gehrman P, Ferreyra H. Lack of night to night variability of sleep disordered breathing measured during home monitoring. Ear Nose Throat J. 2003;82:135-8.
3. Dingli K, Coleman EL, Vennelle M et al. Evaluation of a portable device for diagnosing sleep apnoea / hypopnoea syndrome. Eur Respir J. 2003;21:253-9.
4. Bradley PA, Morimone IL, Douglas NJ. Comparison of polysomnography with Res.Care auto set in the diagnosis of sleep apnoea / hypopnoea syndrome. Thorax 1995;50:1201-3.
Several critics argue that the diagnosis of obstructive sleep apnoea outside a sleep lab will only be cost effective if autotitrating positive airway pressure (APAP) “works”. A recent meta analysis of nine randomized trials comprising of 282 patients showed that APAP and standard CPAP were similar in adherence and equally effective(3).
The cost difference between APAP and in-lab CPAP titration is huge & favours routine APAP in those with high index of clinical suspicion for OSA in the present era of cost cuttings.
Sleep medicine continues to evolve rapidly. The current emphasis is on expedited diagnosis & management of OSA. In several parts of Europe & recently in North America it is now an acceptable practice to use portable monitoring device for determining which patients are eligible for CPAP treatment. New information about CPAP application seems likely to demystify and probably eliminate routine use of in-lab CPAP titrations. However the American Academy of Sleep Medicine continues to oppose the use of portable monitoring in diagnosis of OSA (4,5).
Recently, a multi centre study comparing unsupervised polysomnography (PSG) in patient’s home with PSG supervised at an academic sleep centre showed effectively that portable monitoring is a better predictor of morbidity & mortality than in-lab PSG (6). Similarly another study by Japanese authors showed that simple nocturnal oximetry can be a “valid tool” in selected subgroup of patients when the pretest probability is high as shown by them in obese patients (7). The clinical value of performing full night 16 channel PSG on patients with possible OSA has been questioned by several authors. Douglas et al(8) prospectively analysed sleep data of 200 patients to determine which signals contributed to diagnostic accuracy. Respiratory variables & leg movement sensors were helpful, whereas neuro physiological signals did not contribute significantly to the diagnosis. There is therefore an increasing tendency to use less complicated diagnostic techniques to confirm the diagnosis of OSA. These limited home studies measure more than single channel of oximetry & mostly include respiratory signals. Commonly measured combinations are oximetry, airflow, thoraco abdominal movements & heart rate measurement. There are several new portable devices in the market & this field is changing rapidly (9,10). Many of these portable devices can be conveniently used in patient’s home after adequate instructions. Studies performed in this way can be cost effective, convenient & accurate. However there are several problems with portable devices such as equipment failure, night to night reproducibility & reliability(11). The sensitivity ranges from 32% to 100% & specificity from 33% to 100% compared with full PSG in a sleep centre (12).
A review article published by American academy of sleep medicine gives a classification system for portable monitors based upon the number & type of parameters recorded by each machine(13). Further details about this classification system shall be discussed in my talk & its utility shall be highlighted. It is of paramount importance to understand that clinicians caring for patients with sleep disorders should be familiar with all the limitations associated with any individual sleep monitoring device, particularly if the potential diagnosis of sleep apnoea is refuted. It is equally important to appreciate that the specific technology used for making the diagnosis is less important than the level of experience & training available for interpreting the results.
REFERENCES :
1. Redhine S, Tosteson T, Boucher MA et al. Measurement of sleep related breathing disturbances in epidemiologic studies: Assessment of validity & reproducibility of a portable monitoring device. Chest 1991;100:1281-86
2. Quan SF & the Sleep Heart Health Study (SHHS) Research group; short term variability of respiration & sleep during unattended non laboratory polysomonography. The Sleep Heart Health Study. Sleep 2002;2:843-849.
3. Ayar NT, Patel SR, Malhotra A et al. Auto titrating versus standard CPAP for treatment of OSA results of meta analysis. Sleep 2004;27:249-53.
4. Chesson AL, Berry RB, Pack AP. Practice parameters for use of portable monitoring devices in investigation of suspected OSA in adults. Sleep 2003;26:907-913.
5. Position statement of American Academy of J.Clin.Sleep Med.2006;2:274
6. Iber C, Redhine S, Kaplan Gilpin AM et al. Polysomnography performed in the unattended home versus the attended laboratory setting – Sleep Heart Health Study Methodology. Sleep 2004;27:536-40.
7. Nakano H, Ikeda T, Hayashi M et al. Effect of Body Mass Index on overnight oximetry for diagnosis of obstructive sleep apnoea. Respir Med.2004;98:421-27.
8. Douglas NJ, Thomas S, Jan MA clinical value of polysomnography. Lancet 1992; 339;347-50.
9. Whittle AT, Finch SP, Mortimer IL, Machay TW & Douglas NT use of home sleep studies for diagnosis of sleep apnoea / hypopnoea syndrome. Thorax 1997;52:1968-73.
10. Rees K, Wraith PK, Besthon Jones M & Douglas NJ. Detection of apnoea, hypopnoea & arousals by the Auto set in sleep apnoea/ hypopnoea syndrome Eur. Respir J. 1998;12:76-9.
11. American Academy of Sleep Medicine, American College of Chest Physicians & American Thoracic Society, Evidence review on Home diagnosis of sleep apnoea: a systematic review of literature Chest 2003;124:1543-79.
12. Ross SD, Allan IE, Harrison KJ et al. Systematic review of literature regarding diagnosis of sleep apnoea. Rockville, MD: Agency for Health care policy & Research 1999.
13. Li CK, Ward Flemons W. State of home sleep studies. Clin.Chest Med.2003;24(2):283-95.
FURTHER READING:
1. Douglas NJ Home diagnosis of obstructive sleep apnoea. Sleep Med.Rev.2003;7(1)53-9.
2. Davidson TM, Gehrman P, Ferreyra H. Lack of night to night variability of sleep disordered breathing measured during home monitoring. Ear Nose Throat J. 2003;82:135-8.
3. Dingli K, Coleman EL, Vennelle M et al. Evaluation of a portable device for diagnosing sleep apnoea / hypopnoea syndrome. Eur Respir J. 2003;21:253-9.
4. Bradley PA, Morimone IL, Douglas NJ. Comparison of polysomnography with Res.Care auto set in the diagnosis of sleep apnoea / hypopnoea syndrome. Thorax 1995;50:1201-3.
DO GUIDELINES HELP IN SEVERE COMMUNITY ACQUIRED PNEUMONIA ?
In the face of shifting antimicrobial resistance trends, introduction of new therapeutic options & wide variations in disease severity, the management of severe community acquired pneumonia (SCAP) often requires uncommonly adaptive & customized approaches to patient care(1). With so many changes on the anti-infective landscape, it is not surprising that the diagnosis, risk stratification and antibiotic selection in patients with SCAP continue to challenge clinicians even today(2).
From an institutional & community perspective the therapeutic equation is even more complex. The mandate to both cure patients acutely while preserving long term antimicrobial efficacy in the future represents one of the most important missions that clinicians face when developing protocols & pathways for SCAP (3).
In recent years, treatment strategies for SCAP have evolved significantly, in large part because of changing aetiologic patterns, availability of new agents and increasing antimicrobial resistance especially among strep.pneumoniae which is the leading cause of community acquired pneumonia & bacteremia (4).
Most experts agree that optimizing hospital based management of SCAP requires implementation of process of care strategies that emphasize patient risk stratification according to illness severity followed by appropriate timing, selection and administration of empiric antibiotic therapy & when necessary use of supportive measures (5). The details of various pneumonia severity scores to assess disease severity in SCAP shall be discussed in my presentation. The various professional societies who have issued treatment guidelines for community acquired pneumonia include: American Thoracic Society(ATS), Infectious Disease Society of America (IDSA), American College of Emergency Physicians (ACEP), Centers for Disease Control & Prevention (CDC), British Thoracic Society, Canadian Society of Infectious disease & European Task Force of European Respiratory Society & European Society for Clinical Microbiology & Infectious Diseases (ESCMID) (6-12). These guidelines attempt to identify risk factors associated with drug resistance, poor patient outcomes or infection with specific pathogens requiring modifications in standard therapy. I shall discuss these issues in detail during my talk. While each organization provides treatment recommendations for CAP that are similar & consistent in many ways, there are also subtle differences among them (2). Availability of an extensive armamentorium of antibiotics shown to be effective for CAP – including macrolides, azalides, ketolides, cephalosporins, fluroquinolones, betalactams, carbapenems – further complicates the clinical decision making process(13). Understanding the various risk factors for drug resistance as well as the possible advantages & disadvantages with available therapeutic options endorsed by expert panels & various organizations will best equip busy clinicians to improve clinical outcomes & maximize patient care for SCAP. I shall deal with most of these issues in my talk this afternoon.
REFERENCES :
1. Niederman MS Review of treatment guidelines for community acquired pneumonia. Am J. Med 2004;117:51S –57S
2. Bartlett JG, Mundy M. Community acquired pneumonia NEJM 1995;333:1618-24.
3. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community acquired pneumonia: link between quality of care & resource utilization. Arch. Intern Med. 2002;162:682-88.
4. Heffelfinger JD, Dowell SF et al. Management of community acquired pneumonia in the era of pneumococal resistance. A report from the drug resistant strep.pneumoniae therapeutic working group. Arch. Intern.Med. 2000;160:1399 – 1408.
5. Hanck CD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community acquired pneumonia. Ann Epidemol 2004;14:669-75.
6. Guidelines for management of adults with community acquired pneumonia. Diagnosis, Assessment of severity, Antimicrobial therapy and Prevention. Official statement of ATS Am J Respir Crit Care Med 2001;163:1730 – 54.
7. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM & Whitney C on behalf of IDSA.Update of practice guidelines for the management of community acquired pneumonia in immuno competent adults. Clin Infect. Diseases 2003;37:1405-33.
8. American College of Emergency Physicians clinical policy for management & risk stratification of community acquired pneumonia in adult in emergency department. Ann Emerg. Med 2001;38:107-13.
9. Mandell LA, Marrie TJ, Grossman RF, Chow AW & Hyland RH. Canadian guidelines for initial management of community acquired pneumonia: an evidence based update by the Canadian infectious diseases society and the Canadian thoracic society. Clin Infect. Dis. 2000; 31:383-421.
10. ERS Task force report: Guidelines for management of adult community acquired lower respiratory tract infections. Eur. Respir J. 1998;11:986-91.
11. British Thoracic society, standards of care committee. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001;56:Suppl 4, 1-64.
12. Woodhead M, Blasi F, Ewig S et al. guidelines for the management of adult lower respiratory tract infections. ERS Task force & ESCMID Eur Resp. J 2005;26:1138-80.
13. Moellering RC Jr. The continuing challenge of lower respiratory tract infections. Clin Infect Dis. 2004;38:S319-S321.
FURTHER READING:
1. Feeminghan D, Gruneberg RN The Alexander project 1996-97: latest susceptibility data from international study of bacterial pathogens from community acquired lower respiratory tract infections. J Antimicrob Chemother 2000;45:191-203.
2. Song JH, Lee NJ, Ichiyama S et al. Spread of drug resistant streptococcus pneumoniae in Asian countries: Asian network for surveillance of resistant pathogens (ANSORP) study. Clin Infect Dis 1999;28:1206-11
3. Doern GV, Pfaller MA, Kugler K et al. Prevalence of antimicrobial resistance among respiratory tract isolates of strep. pneumonia in North America: 1997 results from SENTRY antimicrobial surveillance programme. Clin Infect. Dis 1998;27:764-70.
4. Powis J, Mc Geer A, Green K et al. In vitro antimicrobial susceptibilities of strep. pneumoniae clinical isolates obtained in Canada. Canadian bacterial surveillance network. Antimicrob Agents Chemother 2004;48:3305-11.
5. Niederman MS, Feldman C & Richards GA. Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds. Eur Resp. J 2006;27:9-11.
6. Ewig S, Torres A & Woodhead M. Assessment of pneumonia severity: A European perspective. Eur Respir J 2006; 27:6-8.
With best compliments from :
From an institutional & community perspective the therapeutic equation is even more complex. The mandate to both cure patients acutely while preserving long term antimicrobial efficacy in the future represents one of the most important missions that clinicians face when developing protocols & pathways for SCAP (3).
In recent years, treatment strategies for SCAP have evolved significantly, in large part because of changing aetiologic patterns, availability of new agents and increasing antimicrobial resistance especially among strep.pneumoniae which is the leading cause of community acquired pneumonia & bacteremia (4).
Most experts agree that optimizing hospital based management of SCAP requires implementation of process of care strategies that emphasize patient risk stratification according to illness severity followed by appropriate timing, selection and administration of empiric antibiotic therapy & when necessary use of supportive measures (5). The details of various pneumonia severity scores to assess disease severity in SCAP shall be discussed in my presentation. The various professional societies who have issued treatment guidelines for community acquired pneumonia include: American Thoracic Society(ATS), Infectious Disease Society of America (IDSA), American College of Emergency Physicians (ACEP), Centers for Disease Control & Prevention (CDC), British Thoracic Society, Canadian Society of Infectious disease & European Task Force of European Respiratory Society & European Society for Clinical Microbiology & Infectious Diseases (ESCMID) (6-12). These guidelines attempt to identify risk factors associated with drug resistance, poor patient outcomes or infection with specific pathogens requiring modifications in standard therapy. I shall discuss these issues in detail during my talk. While each organization provides treatment recommendations for CAP that are similar & consistent in many ways, there are also subtle differences among them (2). Availability of an extensive armamentorium of antibiotics shown to be effective for CAP – including macrolides, azalides, ketolides, cephalosporins, fluroquinolones, betalactams, carbapenems – further complicates the clinical decision making process(13). Understanding the various risk factors for drug resistance as well as the possible advantages & disadvantages with available therapeutic options endorsed by expert panels & various organizations will best equip busy clinicians to improve clinical outcomes & maximize patient care for SCAP. I shall deal with most of these issues in my talk this afternoon.
REFERENCES :
1. Niederman MS Review of treatment guidelines for community acquired pneumonia. Am J. Med 2004;117:51S –57S
2. Bartlett JG, Mundy M. Community acquired pneumonia NEJM 1995;333:1618-24.
3. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community acquired pneumonia: link between quality of care & resource utilization. Arch. Intern Med. 2002;162:682-88.
4. Heffelfinger JD, Dowell SF et al. Management of community acquired pneumonia in the era of pneumococal resistance. A report from the drug resistant strep.pneumoniae therapeutic working group. Arch. Intern.Med. 2000;160:1399 – 1408.
5. Hanck CD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community acquired pneumonia. Ann Epidemol 2004;14:669-75.
6. Guidelines for management of adults with community acquired pneumonia. Diagnosis, Assessment of severity, Antimicrobial therapy and Prevention. Official statement of ATS Am J Respir Crit Care Med 2001;163:1730 – 54.
7. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher DM & Whitney C on behalf of IDSA.Update of practice guidelines for the management of community acquired pneumonia in immuno competent adults. Clin Infect. Diseases 2003;37:1405-33.
8. American College of Emergency Physicians clinical policy for management & risk stratification of community acquired pneumonia in adult in emergency department. Ann Emerg. Med 2001;38:107-13.
9. Mandell LA, Marrie TJ, Grossman RF, Chow AW & Hyland RH. Canadian guidelines for initial management of community acquired pneumonia: an evidence based update by the Canadian infectious diseases society and the Canadian thoracic society. Clin Infect. Dis. 2000; 31:383-421.
10. ERS Task force report: Guidelines for management of adult community acquired lower respiratory tract infections. Eur. Respir J. 1998;11:986-91.
11. British Thoracic society, standards of care committee. BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001;56:Suppl 4, 1-64.
12. Woodhead M, Blasi F, Ewig S et al. guidelines for the management of adult lower respiratory tract infections. ERS Task force & ESCMID Eur Resp. J 2005;26:1138-80.
13. Moellering RC Jr. The continuing challenge of lower respiratory tract infections. Clin Infect Dis. 2004;38:S319-S321.
FURTHER READING:
1. Feeminghan D, Gruneberg RN The Alexander project 1996-97: latest susceptibility data from international study of bacterial pathogens from community acquired lower respiratory tract infections. J Antimicrob Chemother 2000;45:191-203.
2. Song JH, Lee NJ, Ichiyama S et al. Spread of drug resistant streptococcus pneumoniae in Asian countries: Asian network for surveillance of resistant pathogens (ANSORP) study. Clin Infect Dis 1999;28:1206-11
3. Doern GV, Pfaller MA, Kugler K et al. Prevalence of antimicrobial resistance among respiratory tract isolates of strep. pneumonia in North America: 1997 results from SENTRY antimicrobial surveillance programme. Clin Infect. Dis 1998;27:764-70.
4. Powis J, Mc Geer A, Green K et al. In vitro antimicrobial susceptibilities of strep. pneumoniae clinical isolates obtained in Canada. Canadian bacterial surveillance network. Antimicrob Agents Chemother 2004;48:3305-11.
5. Niederman MS, Feldman C & Richards GA. Combining information from prognostic scoring tools for CAP: an American view on how to get the best of all worlds. Eur Resp. J 2006;27:9-11.
6. Ewig S, Torres A & Woodhead M. Assessment of pneumonia severity: A European perspective. Eur Respir J 2006; 27:6-8.
With best compliments from :
Friday, August 13, 2010
How Do I know If I Have the Flu?
The flu is caused by the influenza virus and can be confused with a cold or a respiratory infection. The flu is different from a cold in that the symptoms begin very suddenly. The most common signs and symptoms of the flu include more shortness of breath than usual, fever, extreme exhaustion, muscle aches (called myalgias) which can last 2-3 weeks, stomach upset, severe coughing without raising sputum and headache. The flu is easily transmitted between people. Like a cold, the flu can be transmitted in the air, or by touching something or someone contaminated with the virus. For example, the flu can be transmitted by inhaling the air near a person with the flu who coughs or sneezes. The flu can also be transmitted by shaking hands with someone with the flu and then touching your nose or eyes. Besides avoiding people with the flu, a person with COPD should be careful to wash their hands after having contact with people with the flu or people suspected of having the flu.
How do I prevent the flu?
Since avoiding people is not very practical, getting a flu shot can reduce your chances of getting the flu. The flu shot must be "renewed" every year because the type of virus causing the flu changes from year to year. The flu shot protects you from the types of viruses that are likely to cause the flu for that year. The shot is no guarantee that you will not get the flu, but it does reduce your chances of getting it.
Can I get the flu from the flu shot?
No, you cannot "get" the flu from the shot. While in the past the flu shot contained the "live" or active form of the virus, this no longer occurs. The way the flu vaccine is now processed does not give people the flu. Sometimes, however, people who were already exposed to the flu get the flu after a shot, but this is a coincidence. It takes 1-2 weeks after you get the shot for the vaccine to give you protection. Soreness where the needle entered the skin or mild aches can occur for 1-2 days after the shot. The flu shot is no guarantee you will not get the flu, but if you get the flu, the seriousness of the flu is often less.
Is the flu dangerous?
The flu can be dangerous for those who are weak or those who get serious respiratory infections easily. People with very severe COPD should be careful not to expose themselves to the flu and should seek immediate medical attention if they have the flu.
What can I do to treat the flu?
You should discuss the treatment of flu with your healthcare provider. Some may want to see you at the first sign of the flu and prescribe medication. If your healthcare provider feels you can handle the flu, you should treat the symptoms by drinking eight glasses of liquids a day, taking acetaminophen/paracetamol for fever, headache and/or muscle aches, resting for exhaustion, and using your inhalers for chest discomfort/tightness.
When should I call my healthcare provider about the flu?
Call your healthcare provider if your symptoms worsen despite treatment or if you cough up sputum that is deep yellow/green in color.
How do I prevent the flu?
Since avoiding people is not very practical, getting a flu shot can reduce your chances of getting the flu. The flu shot must be "renewed" every year because the type of virus causing the flu changes from year to year. The flu shot protects you from the types of viruses that are likely to cause the flu for that year. The shot is no guarantee that you will not get the flu, but it does reduce your chances of getting it.
Can I get the flu from the flu shot?
No, you cannot "get" the flu from the shot. While in the past the flu shot contained the "live" or active form of the virus, this no longer occurs. The way the flu vaccine is now processed does not give people the flu. Sometimes, however, people who were already exposed to the flu get the flu after a shot, but this is a coincidence. It takes 1-2 weeks after you get the shot for the vaccine to give you protection. Soreness where the needle entered the skin or mild aches can occur for 1-2 days after the shot. The flu shot is no guarantee you will not get the flu, but if you get the flu, the seriousness of the flu is often less.
Is the flu dangerous?
The flu can be dangerous for those who are weak or those who get serious respiratory infections easily. People with very severe COPD should be careful not to expose themselves to the flu and should seek immediate medical attention if they have the flu.
What can I do to treat the flu?
You should discuss the treatment of flu with your healthcare provider. Some may want to see you at the first sign of the flu and prescribe medication. If your healthcare provider feels you can handle the flu, you should treat the symptoms by drinking eight glasses of liquids a day, taking acetaminophen/paracetamol for fever, headache and/or muscle aches, resting for exhaustion, and using your inhalers for chest discomfort/tightness.
When should I call my healthcare provider about the flu?
Call your healthcare provider if your symptoms worsen despite treatment or if you cough up sputum that is deep yellow/green in color.
IF THIS PUTS YOU TO SLEEP IT MAY NOT BE THE AD…
GRANTED THE KINDEST THING ANY ONE CAN SAY MOST ABOUT ADVERTISING THESE DAYS IS THAT INDUCES SLEEP.
BUT FOR MANY INDIANS UPTO 5 MILLION, IN FACT-SLEEP DISORDERS GO WELL BEYOND DOZING THROUGH TEDIOUS ADVERTISING.
NOT ONLY ARE SLEEP DISORDERS WIDELY PREVALENT, BUT THEY ALSO REPRESENT A MAJOR NATIONAL HEALTH PROBLEM THAT IS ROUTINELY MISUNDERSTOOD..
SOME EXAMPLES :- THE LADY WHO DREW A MAP OF INDIA ON HER BEDROOM WALL AND THEN FILLED IN THE CAPITALS OF EVERY STATE ALL IN HER SLEEP.
THE AIR TRAFFIC CONTROLLER WHOSE ONLY WAY TO KEEP FROM FALLING ASLEEP ON THE JOB WAS TO STAND WHILE WORKING.
THE EXECUTIVE WITH HEAVY SNORING WHO CHOKED HIMSELF TOO FREQUENTLY AT NIGHTS OR THE TRUCK DRIVER WHO HAD A FATAL ROAD TRAFFIC ACCIDENT BECAUSE HE WAS TOO SLEEPY WHILE DRIVING.
UNFORTUNATELY, THESE STORIES ARE NOT THE WORK OF AN OVERACTIVE IMAGINATION.
THEY ARE THE FRIGHTENING AND OFTEN TRAGIC STUFF OF REAL LIFE, OR REAL PEOPLE LIVING WITH SLEEP DISORDERS THAT MAY GO UNDIAGNOSED FOR YEARS.
THE SOBERING TRUTH IS THAT TWO MILLION INDIANS SUFFER FROM CHRONIC INSOMNIA.
ANOTHER ONE MILLION SUFFER FROM SLEEP APNEA.
ANOTHER THREE MILLION ENDURE SERIOUS SLEEP DISORDERS DUE TO SHIFT WORK.
AT THE INSTITUTE OF SLEEP MEDICINE WE ARE DOING EVERY THING WE CAN TO EDUCATE THE MEDICAL COMMUNITY AND THE PUBLIC ABOUT SLEEP DISORDERS.
BECAUSE WE BELIEVE A BETTER UNDERSTANDING OF SLEEP DISORDERS BY MEDICAL PROFESSIONALS AND PUBLIC AT LARGE COULD IMPROVE THE LIVES OF MILLIONS.
IF YOU WOULD LIKE TO KNOW MORE ABOUT SLEEP DISORDERS PLEASE CONTACT us
AND BY THE WAY IF THIS AD DID PUT YOU TO SLEEP, THAT’S PROBABLY NOT ALL THAT BAD.
YOU MAY WISH TO RETAIN IT FOR YOUR FUTURE BED TIME READING.
BUT FOR MANY INDIANS UPTO 5 MILLION, IN FACT-SLEEP DISORDERS GO WELL BEYOND DOZING THROUGH TEDIOUS ADVERTISING.
NOT ONLY ARE SLEEP DISORDERS WIDELY PREVALENT, BUT THEY ALSO REPRESENT A MAJOR NATIONAL HEALTH PROBLEM THAT IS ROUTINELY MISUNDERSTOOD..
SOME EXAMPLES :- THE LADY WHO DREW A MAP OF INDIA ON HER BEDROOM WALL AND THEN FILLED IN THE CAPITALS OF EVERY STATE ALL IN HER SLEEP.
THE AIR TRAFFIC CONTROLLER WHOSE ONLY WAY TO KEEP FROM FALLING ASLEEP ON THE JOB WAS TO STAND WHILE WORKING.
THE EXECUTIVE WITH HEAVY SNORING WHO CHOKED HIMSELF TOO FREQUENTLY AT NIGHTS OR THE TRUCK DRIVER WHO HAD A FATAL ROAD TRAFFIC ACCIDENT BECAUSE HE WAS TOO SLEEPY WHILE DRIVING.
UNFORTUNATELY, THESE STORIES ARE NOT THE WORK OF AN OVERACTIVE IMAGINATION.
THEY ARE THE FRIGHTENING AND OFTEN TRAGIC STUFF OF REAL LIFE, OR REAL PEOPLE LIVING WITH SLEEP DISORDERS THAT MAY GO UNDIAGNOSED FOR YEARS.
THE SOBERING TRUTH IS THAT TWO MILLION INDIANS SUFFER FROM CHRONIC INSOMNIA.
ANOTHER ONE MILLION SUFFER FROM SLEEP APNEA.
ANOTHER THREE MILLION ENDURE SERIOUS SLEEP DISORDERS DUE TO SHIFT WORK.
AT THE INSTITUTE OF SLEEP MEDICINE WE ARE DOING EVERY THING WE CAN TO EDUCATE THE MEDICAL COMMUNITY AND THE PUBLIC ABOUT SLEEP DISORDERS.
BECAUSE WE BELIEVE A BETTER UNDERSTANDING OF SLEEP DISORDERS BY MEDICAL PROFESSIONALS AND PUBLIC AT LARGE COULD IMPROVE THE LIVES OF MILLIONS.
IF YOU WOULD LIKE TO KNOW MORE ABOUT SLEEP DISORDERS PLEASE CONTACT us
AND BY THE WAY IF THIS AD DID PUT YOU TO SLEEP, THAT’S PROBABLY NOT ALL THAT BAD.
YOU MAY WISH TO RETAIN IT FOR YOUR FUTURE BED TIME READING.
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