The Proportional Venn Diagram of Obstructive Lung Disease. Part 6
In the subpopulation of participants aged > 50 years, the prevalence of current asthma was 5.1%, the prevalence of current chronic bronchitis was 5.8%, and the prevalence of ever having had emphysema was 5.0% in the US NHANES III survey. In the UK GPRD subpopulation of participants aged > 50 years, the prevalence of current asthma was 1.6%, the prevalence of current chronic bronchitis was 1.1%, and the prevalence of current emphysema was 1.1% (data not shown). The seven mutually exclusive disease groups of this proportional Venn diagram also can be displayed as stacked bars, for comparison by gender and age (Fig 3). The relative size of the asthma-only group decreased with increasing age, both in women and men in the United States and the United Kingdom. In the NHANES III data, probably because acute bronchitis could have been misclassified as chronic bronchitis in some cases via the self-reported questionnaire, combinations of chronic bronchitis with asthma or chronic bronchitis alone appeared at very young ages. Emphysema was reported consistently from age 50 years onward. Combinations of two of the three OLD conditions occurred among 21.2%, 31.4%, and 14.4%, in those patients in the age groups of 60 to 69 years, 70 to 79 years, and > 80 years, respectively.
By contrast, in the UK GPRD, emphysema and chronic bronchitis are virtually nonexistent diagnoses before 50 years of age. After age 50 years, the frequent diagnoses of chronic bronchitis and emphysema together as COPD gave little room for chronic bronchitis-only or emphysema-only diagnoses. Therefore, combinations of two of the three OLD conditions occurred among 41.5%, 58.8%, and 65.5% of patients in the age groups of 60 to 69 years, 70 to 79 years, and > 80 years, respectively.
Finally, according to the spirometry data of NHANES III, US OLD participants with chronic bronchitis or emphysema, with or without a concomitant diagnosis of asthma, differed widely regarding the prevalence of airflow obstruction among patients with a diagnosis of emphysema only, with only 37.4% of patients having airflow obstruction confirmed by spirometry. The prevalence of airflow obstruction was significantly higher among participants with combinations of emphysema and chronic bronchitis (57.7%), with emphysema and asthma (51.9%), and with all three OLD diseases concomitantly (52.0%). Among all NHANES III participants with airflow obstruction, accounting for 4.8% of the general population, 58.3% reported no diagnosis of any of the three OLD conditions (Fig 4). The patterns of airflow obstruction prevalence were confirmed when the analysis was restricted to participants aged > 50 years (Fig 5). The prevalence of airflow obstruction in the seven mutually exclusive areas were as follows: asthma only, 26.5%; chronic bronchitis only, 29.6%; emphysema only, 45.5%; asthma plus chronic bronchitis, 55.8%; asthma plus emphysema, 48.7%; chronic bronchitis plus emphysema, 59.7%; and asthma plus chronic bronchitis plus emphysema, 49.0%. Still, 9.3% of the NHANES III population who were > 50 years of age had objective airflow obstruction without any respiratory diagnoses.
The Proportional Venn Diagram of Obstructive Lung Disease. Part 5
Before testing, screening questions were asked to determine medical safety exclusions (ie, those who had undergone chest or abdominal surgery within 3 weeks or had experienced heart problems [myocardial infarction or heart attack, angina or chest pain, and congestive heart failure]) within 6 weeks before attending the MEC. Airflow obstruction was defined as stage 1 according to the following Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines: FEV1, < 80% of predicted (based on gender, age, and height); FEVj/FVC ratio, < 70%.4 As children aged < 7 years did not have spirometry measurements recorded in NHANES III, estimates of airflow obstruction were weighted to the sample of participants aged > 8 years for whom spirometry had been measured.
Statistical Analysis
The prevalence for each condition per gender and age group is presented for the United States and the United Kingdom separately. Values have been extrapolated to the total population in each country using the NHANES III sample weights for the United States and using the Office of National Statistics data for the United Kingdom. Each graphic representation in Figures 2 to 5 was calculated by applying simple proportional euclidean geometry, with the area of the circle representing the exact population size. The areas of intersection of circles represent the percentage of overlap of two or three OLD conditions. Analyses were conducted using a statistical software package (SAS, version 8.0; SAS Institute; Cary, NC).
Results
The descriptive characteristics of NHANES III and GPRD participants with OLD are presented in Table 1. Patients were stratified into seven mutually exclusive disease groups by age and sex for each study population. Patients with asthma, in whom diagnoses had been made with or without other OLD conditions, were younger than COPD patients. The combination of asthma with chronic bronchitis, but not with emphysema, was associated with younger age.
In the US NHANES III total population, the prevalence of current asthma was 5.5%, the prevalence of current chronic bronchitis was 3.2%, and the prevalence of ever having had emphysema was 1.5%. In the UK GPRD total population, the prevalence of current asthma was 2.3%, the prevalence of current chronic bronchitis was 0.5%, and the prevalence of current emphysema was 0.5% (Fig 2). The asthma-only group was the largest group of OLD patients, accounting for 4.3% and 2.2%, respectively, of the United States and United Kingdom general populations; that is, 50.3% and 79.4%, respectively, of all OLD patients. Seventeen percent of OLD patients in the United States had more than one OLD condition, and 2.8% had all three conditions simultaneously. The UK figures were 19.1% and 3.6%, respectively. The areas of intersection among the three OLD conditions differed by data source and country (Fig 2).
The Proportional Venn Diagram of Obstructive Lung Disease. Part 4
Such patients often are referred to in the United States as having asthmatic bronchitis or the asthmatic form of COPD. Persons with chronic bronchitis and/or emphysema without airflow obstruction (ie, subsets 1, 2, and 11) are not classified as having COPD. Patients with airway obstruction due to diseases with known etiology or specific pathology, such as cystic fibrosis or obliterative bronchiolitis (subset 10), are not included in this definition. Reprinted with permission from the American Thoracic Society. of a hospital or other specialist visit (ie, inpatient, outpatient, or in an accident and emergency unit) must be recorded when the GP is informed. The diagnosis, symptoms, procedure or investigation, referrals, and their outcome must be entered into the relevant sections of the medical record. In this report, estimates are presented for patients who attended their GP, were given a diagnosis of asthma or COPD, and were registered throughout 1998. Pulmonary function data are not systematically or routinely available.
Case Definitions
Definitions of OLD in each database differ. NHANES III was a survey, and the questionnaire part of the survey asked participants about self-reported physician-diagnosis of three conditions (ie, asthma, chronic bronchitis, and emphysema). A positive response to the single question “Has a doctor ever told you that you have emphysema?” was sufficient to define emphysema. But, for asthma and chronic bronchitis, positive responses to the following two questions were necessary to define a current condition: “Has the doctor ever told you that you have [asthma or chronic bronchitis]?” and ”Do you still have it?“ A participant could be classified as having ah three conditions.
The GPRD system uses the Oxford Medical Information System (OXMIS) and READ coding system (the first three digits of the OXMIS number corresponds, in most cases, to the first three digits of the International Classification of Diseases, eighth revision, codes). Physician-diagnosed asthma, chronic bronchitis, and emphysema were defined as any individual who was labeled with one or more of the OXMIS/READ codes that were compatible with their respective diagnoses during calendar year 1998. This permitted the use of terms like COPD without reference to chronic bronchitis or emphysema. Acute bronchitis was excluded from the algorithm. The choice of GPRD OXMIS/ READ codes was recorded by each individual GP without instructions or guidelines. Direct codes for COPD were defined as overlapping chronic bronchitis and emphysema in the Venn diagrams.
Spirometry in NHANES III
Lung function testing was conducted on participants aged > 8 years by a trained technician in a mobile examination center (MEC). Testing also was conducted at the home of participants aged > 60 years who were unwilling or unable to come to the MEC.
Top Ten List in Ventilator-Associated Pneumonia (Part 5)
This study tested the potential value of routine microbiological cultures before VAP onset in predicting the causative pathogen of VAP and in anticipating the correct antibiotic choice. Authors cultured blood, respiratory secretions, catheter-tips, urine, and others substances, and found that there was no relationship between the colonization of tissues other than from the lungs and the etiology of VAP. High-quality distal bronchial samples obtained by BAL and protected-specimen brush, if cultured in the previous 72 h, had positive predictive values of 25% and 28%, respectively. Only distal respiratory secretions, when repeated at intervals between 48 and 72 h, might have a role in predicting the causative bacteria of VAP. Special attention is required for potentially drug-resistant bacteria like methicillin-resistant Staphylococcus aureus, P aeruginosa, and Acinetobacter baumannii with positive predictive values of 62%, 52%, and 24%, respectively. Previous colonization with any of these pathogens implies a high risk for subsequent pneumonia, allowing for an adequate empiric antibiotic selection.
The authors present the largest study performed in the United States, comprising 842 VAP patients and 2,243 control subjects. The mean interval between intubation and the identification of VAP was 3.3 ± 6.6 days. A crude incidence of 9.3% was found in ventilated patients. The authors also reported morbidity and economic variables resulting in an increase in mean ICU and hospital stays (6.1 days), mean period of mechanical ventilation (9.6 days), and a mean doubled increase in hospital charges ($41,294). P aeruginosa was isolated most frequently in patients with VAP, occurring > 4 days after the start of mechanical ventilation (19.7%), while S aureus was isolated most frequently in patients in whom VAP was diagnosed before the fourth day of onset of mechanical ventilation (23.7%). They found no attributable mortality at 30 days. An outstanding conclusion is that intermediate underlying illness severity is one of the independent risk factors for developing VAP, as reported previously for late-onset VAP episodes caused by P aeruginosa. The main goal of this study concerned the impact on the design of future studies aimed at VAP prevention.
Top Ten List in Ventilator-Associated Pneumonia (Part 4)
This expert group investigated the potential role of nonpathogenic microorganisms in VAP. Three hundred sixty-nine VAP patients were identified during the study period. Only 29 episodes were considered to have been caused by commensal pathogens. The percentage of pathogens of unknown etiology was not reported. Polymicrobial VAP was found in 77 patients, and these patients were excluded from the study. Most patients had risk factors for more virulent or resistant pathogens like COPD, glucocorticoid therapy, or immunosuppression. Although the onset of 10 cases occurred before the sixth ICU day, all Gram-negative commensal pathogens that were isolated were sensitive to therapy with a third-generation cephalosporin or amoxicillin/clavulanic acid. Seven of 29 patients did not receive adequate treatment, and mortality did not increase significantly. Although the authors attribute a pathogenic role to commensal bacteria, they did not find any difference in mortality rate between patients with or without VAP. In addition, besides the limited relevance to mortality, only 20% of patients who died had received histologic confirmation of a diagnosis of pneumonia. Commensal pathogens can produce fulminant infections in immunocompromised patients, but this is the first study that has suggested the need to treat commensal isolates in patients with VAP. Future investigations are needed to define the pathogenic role of commensal agents in these kinds of patients.
The occurrence of and effect on prognosis of delays in the beginning of the treatment of VAP have not been reported before, to our knowledge. Appropriate initial antibiotic treatment has been reported to reduce in-hospital mortality. Iregui et al have found an increase in the hospital mortality rate with delayed initial treatment. Adequate initial treatment usually has been defined as an antibiotic with in vitro susceptibility to the pathogen isolated in respiratory samples. This definition needs the addition of onset timing in antibiotic administration. The most common cause of inadequate initial treatment was a delay in writing the medical orders. The presence of a resistant organism accounted for < 20% of cases. It is important to note that diagnostic delays were not counted, although radiologic criteria included an infiltrate persistence of > 72 h. Inadequate clinical evaluation and waiting for microbiological results were reasons of delayed empiric treatments.
Top Ten List in Ventilator-Associated Pneumonia
Rello J, Lorente C, Bodi M, et al. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?
The article reflects the need to improve medical and nursing staff adherence to guidelines. A total of 110 opinion leaders on VAP from 22 countries were interviewed for their personal opinions on different VAP prevention measures Dapoxetine online. Scientific evidence published alone has been shown to be ineffective in improving guideline implementation because the degree of adherence is independent of the strength of evidence and the grade of effectiveness, at least in part because of the disagreement of opinion leaders about the interpretation of reported trials. However, the most important reason why recommendations are not followed is the lack of technological availability, which has been cited by 78% of the interviewed opinion leaders. Pharmacologic strategies had worse adherence than nonpharmacologic ones, which were predominantly conditioned for excessive antibiotic employment. This report highlighted the great importance of educational measures in improving VAP prevention, remarking on the need for a multidisciplinary approach.
Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.
This interesting article confirms the huge importance of implementing scientific data with educational programs, and is directed to physicians and nurses in an effort to improve VAP prevention. The reduction in the VAP rate reported is 57.6% (range, 12.6 to 5.7 episodes per 1,000 ventilator days). The program included a theoretical module, with selfstudy and practice modifications, with staff meetings and didactic lectures. The authors reinforced the programs with continuous visual support throughout the ICU, contributing to the adherence to the guidelines. These strategies require constant reinforcement by continuous updating and feedback based on results. It is important to point out that the combination of different measures is an important way to reduce the incidence of VAP. As can be inferred from the study, not only the incidence of VAP can be reduced with educational programs, but also the costs and patient morbidity attributed to nosocomial infections.
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What Makes A Depressed Person Want To Push You Away And Be Alone?
Depression causes a variety of reactions. The reactions may or may not be intended, real or imagined. With depression, certain chemicals in the brain become unstable, causing people to think rather irrationally. Many times, the sad feelings are so intense that for a lot of people, the only way to cope with them is to retreat themselves away from others or push their loved ones away.
Possible Reasons Why Depressed Persons Push Their Loved Ones Away
There could be several reasons why depressed individuals feel the need to push their loved ones away, among them:
- Depressed individuals are hopeless beyond hope that they feel nobody else can help them.
- There is a tendency to feel threatened or overwhelmed by the presence of loved ones.
- Depressed individuals love their family and loved ones so much that they would not want to drag them into the “mess” they feel they are in.
- In worse cases, severe depression can make people delusional and paranoid that they may see their loved ones as “enemies”.
While the tendency to push loved ones away is real, it does not mean that it is okay. If you are at the other end, allowing your loved one to push you away because he or she is suffering from depression will only bring more harm than good to both of you. Keep in mind that your “significant other” is at a very low point at the moment, and even though he or she may not realize it, your loved one actually needs your love and support.
Reversing Depression
Let your loved one know that you are not the type of person who will leave her in the dark nor are you someone who will just take no for an answer.
So here are some things you can try to do to reverse depression and make your loved one feel better:
- Stay with him/her while giving him/her space at the same time. Give him/her time to sort his/her emotions, but don’t let him/her mope. You don’t necessarily have to say anything. Just be there to hold his/her hand and to offer your shoulder when he/she needs to lean on to someone.
- Take your loved one somewhere fun. A park with a playground and children playing is a nice place to spend a cool afternoon. Watching kids play and hearing them laugh is very good to the senses. Who knows, you might actually get your loved one to smile.
- Get your loved one to eat ice cream. Who doesn’t love the thought of ice cream, especially on a sunny day? There’s something about ice cream that takes us back to the time when we were little kids, a time when we didn’t have a care in the world, a time when we didn’t have time to be sad.
- Watch DVDs. Spend all afternoon just watching light and funny flicks. As much as possible, have the lights on. Being in dark places will not do anything to lift the mood of your loved one.
- Keep in mind that depression should never last for more than a few days. If none of the above helps to reduce your loved one’s feeling of sadness and if your loved one is already exhibiting signs and symptoms that affect his/her health (not sleeping very well or sleeping too much, not eating or overeating, having palpitations and panic attacks ), do the next best thing – get your loved one to see a counselor or a therapist.
Untreated depression can progress into something much worse and you really don’t want that to happen. Even severe depression has good chances of getting healed completely if treatment has begun early on.
Depression Medication – Questions to Ask Your Doctor
Going on medication of any kind is a big step. Many people still see their doctor as an authority figure who should not be questioned. Consulting with your doctor or health professional on depression medication is especially difficult due to the stigma related to mental illness and the inherent vulnerability stemming from the subject matter. Below is a list of essential questions to ask your doctor before going on medication. Many people find it useful to print out the list and carry it with them. I would suggest writing down the answers. The amount of information given in a short consultation is hard to remember. If your doctor is unwilling or unable to answer the following questions I would suggest a second opinion. New drugs may be less familiar to them but there are many different ways they can access the information to answer your questions during your consultation. It’s a two way street, for doctors to make appropriate recommendations about medication they need all the facts about your symptoms and past medical history.
*What are the reasons for choosing this medication over other alternatives?
*What will the medication do?
*What are the side effects?
*How long will the side effects last?
*How long before it works?
*What is involved in coming off the drug?
*What are the other options?
*Are they any precautions? (e.g. other medications or previous illness)
It’s important to be aware that medication may give relief but the psychological and lifestyle factors that are contributing to depression still need to be addressed Medication may give you the motivation to attend to the problems that are holding you back from recovery. Remember it is your choice. You have the right to consult another doctor. To explore natural therapies. To change medication if after giving it a trial it’s not right for you
If you are still not sure do more research ask your pharmacist, naturopath, find reputable sources of information on the internet or ask your doctor for any written material they may have on the drug. Discuss it with trusted friends, you will be surprised once you start the conversation how many people have tried different medications at different times in their life. Their experience though individual and dependent on their particular situation is still valuable information to help you decide what is right for you. It may take some trial and error and some patience but if you find something that helps you get your life back on track then its worth it.
How to Combat Postpartum Depression
Do you think you have postpartum depression? Don’t worry because there is nothing wrong with you. Postpartum depression affects most mothers, especially new moms. It is also commonly known as “baby blues” and it is caused by the sudden changes in your hormones. Most women experience the symptoms of postpartum depression for about a week; however, it can also last longer in some women.
Before you learn about how to combat postpartum blues, it is very helpful for you to learn how to identify its symptoms. These symptoms are quite similar to that of normal depression; however, they do not last very long. Usually mothers with post partum depression often are irritable which is why they can get easy angry and upset by even the smallest things. Exhaustion is also very common. Also, they also tend to pull away from their baby. They may even try to ignore their responsibilities as a mother and have someone else take care of their baby. One reason for this is that they get anxious about how well they can do their responsibilities and they are afraid that they will just harm their baby. This can even resort to panic attacks.
Other symptoms for postpartum depression include changes in appetite, sleep pattern disturbances, low libido, and fatigue. A confirmatory sign is an unexplainable constant feeling of sadness or guilt.
If you do have postpartum blues, there are several ways to combat it, so don’t worry.
- The first thing to do is to take care of yourself and you should start with getting enough rest and sleep. Lack of quality rest can lead to irritability and fatigue.
- Another way to combat postpartum depression is to express your feelings. It will help give you peace of mind and help lessen the stress and anxiety you feel. Talking to someone about may seem very basic, but it really does help. Sometimes all you really need is someone to be there for you. Try talking to someone you can easily relate with, or someone that has also been through the baby blues.
- If you have a therapist, then you can talk to him as well. While medications are also available for treating postpartum depression, most physicians will tell you that regular counselling is still the most effective treatment for helping women cope with their depression.
- If counselling doesn’t work, antidepressants are prescribed to help new mothers overcome postpartum depression. Other doctors also prescribe psychotherapy such as the Emotional Freedom Technique which uses both psychology and acupuncture.
If you are pregnant and are worried about postpartum depression, don’t be. There are several ways of combating it. Another good thing is that not all pregnancies will result to it. Not all mothers will experience it, and even if you get it when you deliver your first baby, it doesn’t mean that you will also experience it on your next pregnancy. Postpartum depression is easily treatable, so get treated as early as you can. Don’t wait until it gets out of control before you start doing something about it.
The Brain, Use It or Lose It
This old, but true saying applies to our body the same way. Centuries ago, during a more unsanitary time, our gallbladder had a major role in fighting germs and food breakdown. Now, due to proper cooking of foods, the gallbladder has become unused, unneeded, and has deteriorated in size and function.
The human body is very adaptable and has the potential to adapt according to our environment given enough time. Modern times, especially since the industrial revolution, have created something that the human body has found itself incapable of adapting to. The demands of a faster paced society, deadlines, and a state of always being in a hurry have destroyed our body’s harmony. Your body and brain has been programmed to run at a faster speed than was intended. We don’t take time to properly rest and give the brain time to properly reflect on activities before the next has started. To make things worse, we rely on modern conveniences and have become less physically active.
The brain in ways is a super computer controlling and regulating every aspect of our body. Our body is loaded with safety programs, just like a computer. The presence or lack of a hormone tells the brain to turn on or off something else. What happens to your computer if the firewall gets turned off? It becomes vulnerable to attacks. The brain is no different; it has its own firewall called serotonin (natural shield). Serotonin, at normal levels, creates a natural shield that protects us from falling apart and is produced during exercise. While indulging ourselves with all the modern conveniences and becoming less active we have been training our brains to produce less and less serotonin.
As we replace our serotonin, we are in fact building up mental/spiritual roadblocks. These roadblocks affect our ability to think clearly and allow for fear and doubt to control our decisions and actions.
The absence of, or low serotonin levels have disarmed our firewall making our brains very vulnerable to depression, stress, and anxiety. To further complicate the problem, we as a society have begun relying on antidepressants to replace the role of our serotonin.
As we slowly replace our serotonin with pharmaceuticals we send the message to our brain that we need less and less so the brain produces less. This in turn causes us to require larger doses or stronger pharmaceuticals to make us feel better.
As our brains slowly stop producing serotonin, and has been replaced with pharmaceuticals there comes a point where the brain forgets how to make its own serotonin.
Have we reached a point where some may say they don’t need it? We have food processing companies so we don’t need our gallbladder. We have pharmaceutical companies so we don’t need serotonin.
Therapeutic levels of serotonin can be rebuilt through a carefully planned fitness approach such as the W.A.R. (worry, adrenaline, rest) method from Building The Temple Therapeutic Fitness program.
The solution is within our lifestyle changes. Exercise and being active produces serotonin. Medications for mood stabilization should only be used for short periods of time to avoid dependency. Usage during the period of exercising to build up serotonin levels is ideal, but should be stopped when a therapeutic serotonin level has been achieved. This should only be done under the supervision of a physician.