Post Exposure Prophylaxis (PEP) Occupational exposure Occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV and HCV) that may occur in healthcare settings during performance of job duties. Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimise the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV). This includes counselling, risk assessment, relevant laboratory investigations based on informed consent of the source and exposed person, first aid and depending on the risk assessment, the provision of short term (four weeks) of antiretroviral drugs, with follow up and support. Who is at risk? All Health Care Personnel, including emergency care providers, laboratory personnel, autopsy personnel, hospital employees, interns and medical students, nursing staff and students, physicians, surgeons, dentists, labour and delivery room personnel, laboratory technicians, health facility sanitary staff and clinical waste handlers and health care professionals at all levels. Also at risk are public safety workers, including law enforcement personnel, prison staff, fire-fighters, workers in needle exchange programme and workers in HIV programmes. What is the risk? Health Care Personnel are at risk of blood-borne infection transmission through exposure of a percutaneous injury (e.g. needle-stick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth of an infected person, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis or contact with blood or other potentially infectious body fluids. potentially infectious body fluids Any direct contact (i.e., contact without barrier protection) with concentrated virus in a research laboratory or production facility requires clinical evaluation. Transmission of HIV infection from human bites is rarely reported. The average risk of acquiring HIV infection from different types of occupational exposure is low compared to risk of infection with HBV or HCV. In terms of occupational exposure the important routes are needle stick exposure (0.3% risk for HIV, 9–30% for HBV and 1–10% for HCV) and mucous membrane exposure (0.09% for HIV).e What is infectious and what is not? Exposure to blood, semen, vaginal secretions, cerebrospinal fluid, synovial, pleural, peritoneal, pericardial fluid, amniotic fluid and other body fluids contaminated with visible blood can lead to infection. Exposure to tears, sweat, saliva, urine and faeces is non-infectious unless these secretions contain visible blood. Step 1: First aid in management of exposure For skin — if the skin is broken after a needle-stick or sharp instrument:
April-june-2011.pmd[Indian J Chest Dis Allied Sci 2011;53:121-125]
Community Pharmacy-Based Asthma Services—What Do Patients Prefer?
Pradnya Naik Panvelkar, Carol Armour and Bandana Saini
Journal of Asthma 2010;47:1085-1093 Background. Patient preferences can influence the
their pharmacists to provide were the provision of outcomes of treatment and so understanding and information about asthma and its medications, lung organizing health-care services around these function testing and monitoring of their asthma, and preferences is vital.
checking/correcting their inhaler technique. Patients Objective. To explore patient preferences for types of
also expressed a desire for skilled communication community pharmacy-based asthma services, to and behavioral aspects from the pharmacist such as investigate the influence of "experience" in the friendliness, empathy, attentiveness, and dedicated molding preferences for such services, and to identify time. Patients highlighted the importance of privacy aspects of the services that patients prefer over others.
in the pharmacy. There was a high level of Methods. Semistructured face-to-face interviews were
satisfaction toward the currently delivered asthma conducted with a convenience sample of two types of service among both naïve and experienced patient. The asthma patients: (1) those naïve to a specialized provision of the specialized service was associated asthma service and (2) those who had experienced a with increased patient loyalty to the particular specialized asthma service. Interviews were audio- pharmacy. All patients indicated a willingness to recorded, transcribed verbatim, and thematically participate in future pharmacy-delivered specialized asthma services.
Results. Eighteen interviews were conducted (8
Discussion. Elements of the specialized pharmacy-
experienced patients, 10 naïve patients. The majority of based asthma services important from a patient's the patients wanted the pharmacist to play a greater perspective were identified. It would be important to role in their asthma management. Patients identify the strength and magnitude of patient's experiencing increased levels of service had increased preferences for different elements of such services.
levels of expectations as well as more specific Future pharmacy-based services should incorporate preferences for various aspects of the service. The key patient preferences and tailor services to patient's aspects of an asthma service that all patients wanted needs to ensure their long-term viability.
Difference Between Patient-reported Side Effects of Ciclesonide versus
Thys van der Molen, Juliet M. Foster, Manfred Caeser, Thomas Muller, Dirkje S. Postma
Respiratory Medicine 2010;104:1825-1833 Rationale. Patient-reported outcomes provide new
studies: 1) once daily ciclesonide 320 μg (n = 234) or insights into the dynamics of asthma management.
twice daily fluticasone propionate 200 μg (n = 240); 2) Further to asthma control and quality of life, self- twice daily ciclesonide 320 μg (n = 255) or twice daily reported side effects of treatment can be assessed with fluticasone propionate 375 μg (n = 273); and 3) twice the validated Inhaled Corticosteroid Questionnaire daily ciclesonide 320 μg (n = 259) or twice daily fluticasone propionate 500 μg (n = 244). Patients rated Objectives. To compare patient-reported side effects
the side effect questions of the 15 domain ICQ on a 7- between the inhaled corticosteroids ciclesonide and point Likert scale (0 = not at all, 6 = a very great deal) during scheduled visits.
Methods. Patients with moderate or moderate-to-
Results. The majority of side effect scores remained
severe asthma, pre-treated with a constant dose and similar with ciclesonide but worsened statistically type of medication, were randomized in three separate significantly with fluticasone propionate from baseline to the end of the study in within-treatment Conclusion. Patient-perceived side effects differ
analyses. In between-treatment analyses of studies 1 depending on the type of inhaled corticosteroids and 3 ciclesonide significantly improved total side used. Patients with moderate-to-severe asthma effect scores (p < 0.025) and 14 out of 30 individual report less intense side effects assessed with local and systemic domain scores (p < 0.025) ICQ with ciclesonide than with fluticasone compared with fluticasone propionate. In Study 2, although ciclesonide improved the majority of scores compared with fluticasone propionate only Clinical trial registration. The reported trials were
‘oropharyngeal itching' reached statistical completed before July 1 2005 and, therefore, are not significance (p < 0.025, one-sided).
Patients' Prediction of Extubation Success
Andreas Perren, Marco Previsdomini, Michael Llamas, Bernard Cerutti, Sandor Gyorik,
Giorgio Merlani, Philippe Jolliet
Intensive Care Medicine 2010;36:2045-2052 Purpose. The spontaneous breathing trial (SBT)—
Results. Extubation success was more frequent in
relying on objective criteria assessed by the confidents than in non-confidents (90 vs. 45%; p < 0.001/ clinician— is the major diagnostic tool to determine if positive likelihood ratio = 2.00) or in the control group patients can be successfully extubated. However, little (90 vs. 78%; p = 0.04). On the contrary, extubation is known regarding the patient's subjective failure was more common in non-confidents than in perception of autonomous breathing.
confidents (55 vs. 10%; p < 0.001/negative likelihood Methods. We performed a prospective observational
ratio = 0.19). Logistic regression analysis showed that study in 211 mechanically ventilated adult patients extubation success was associated with patient's successfully completing a SBT. Patients were prediction [OR (95% CI): 9.2 (3.74-22.42) for confidents randomly assigned to be interviewed during this vs. non-confidents] as well as to age [0.72 (0.66-0.78) for trial regarding their prediction of extubation age 75 vs. 65 and 1.31 (1.28-1.51) for age 55 vs. 65].
success. We compared post-extubation outcomes in Conclusions. Our data suggest that at the end of a
three patient groups: patients confident (confidents; n sustained SBT, extubation success might be = 115) or not (non-confidents; n = 38) of their correlated to the patients' subjective perception of extubation success and patients not subjected to autonomous breathing. The results of this study interview (control group; n = 58).
should be confirmed by a large multicenter trial.
BCG Vaccination Status may Predict Sputum Conversion in Patients with
Pulmonary Tuberculosis: A New Consideration for an Old Vaccine?
Kidola Jeremiah, George PrayGod, Daniel Faurholt-Jepsen, Nyagosya Range, Aase B. Andersen,
Harleen M. S. Grewal, Henrik Friis
Background. Failure to convert (persistent sputum
pulmonary TB in Mwanza, Tanzania. Information on and/or culture positivity) while on antituberculosis social demographic characteristics, anthropometric (anti-TB) treatment at the end of the second month of measurements, BCG scar status, HIV status, CD4+ anti-TB therapy has been reported to be a predictor of count, white blood cell count, haemoglobin and treatment failure. Factors that could be associated sputum culture status was obtained.
with persistent bacillary positivity at the end of the second month after initiation of anti-TB treatment Results. Factors associated with sputum culture non-
conversion at the end of the second month of anti-TB Methods. A prospective cohort study was conducted
treatment were initial acid-fast bacilli (AFB) culture in 754 patients with sputum culture positive grading of 3+ (OR 5.70, 95% CI 1.34 to 24.31, p=0.02) The Indian Journal of Chest Diseases & Allied Sciences
and absence of a BCG scar (OR 3.35, 95%CI 1.48 to findings reflect a beneficial role for BCG vaccination 7.58, p=0.004).
on sputum conversion which should also be Conclusions. Patients with pulmonary TB with no
examined in large studies in other areas. The finding BCG scar and high initial AFB sputum intensity are of a beneficial role for BCG vaccination on the at risk of remaining sputum culture positive at the end treatment of pulmonary TB is important for TB of the second month of anti-TB treatment. These control and vaccination programmes.
Exercise Decreases Plasma Antioxidant Capacity and Increases Urinary
Isoprostanes of IPF Patients
R. Jackson, C. Ramos, C. Gupta, O. Gomez-Marin
Respiratory Medicine 2010;104:1919-1928 We tested whether markers of systemic oxidant stress exercise, suggesting pulmonary arterial hypertension.
were detectable in 29 typical IPF patients, and IPF patients' resting NT-proBNP concentrations whether these increased after low level exercise. We apparently exceeded those of normal controls. IPF obtained resting plasma for measurement of amino plasma isoprostanes at rest exceeded the normals.
terminal pro brain natriuretic peptide (NT-proBNP), IPF urine isoprostanes increased significantly after and plasma and urine samples for isoprostanes and exercise (P = 0.047 by signed rank test); and, plasma total nitrite. Total antioxidant capacity (TAC) was TAC decreased significantly after exercise (P < 0.001 measured in plasma, and H O was measured in by signed rank test). Neither plasma nor urine nitrite urine. Subjects exercised at 50 W on a semi recumbent changed significantly after exercise. H O concen- bicycle until limited by dyspnea. Samples were tration was quite high after exercise in some IPF obtained immediately after exercise for measurement subjects' urine.
of the same variables.
IPF patients demonstrate systemic oxidant stress at Plasma and urine samples were also obtained at rest detectable as increased isoprostanes in the rest from 6 normal individuals over 40 years of age circulation. An increase in urine isoprostanes and a solely to establish comparison values for NT-proBNP, decrease in plasma TAC after exercise suggest that nitrite, H O and TAC assays.
reactive oxygen species (ROS) are produced during Plasma NT-proBNP was high at rest and after low level exercise done by IPF patients.
Exhaled Nitric Oxide Thresholds Associated with a Sputum Eosinophil
Count ≥3% in a Cohort of Unselected Patients with Asthma
Florence N. Schleich, Laurence Seidel, Jocelyne Sele, Maite Manise, Valerie Quaedvlieg,
Alain Michils, Renaud Louis
Background. It has been claimed that exhaled nitric
logistic regression analysis were used to assess the oxide (FeNO) could be regarded as a surrogate marker relationship between sputum eosinophil count and for sputum eosinophil count in patients with asthma.
FeNO, taking into account covariates such as inhaled However, the FeNO threshold value that identifies a corticosteroids (ICS), smoking, atopy, age and sex.
sputum eosinophil count ≥3% in an unselected Results. Derived from the ROC curve, FeNO ≥41 ppb
population of patients with asthma has been poorly gave 65% sensitivity and 79% specificity (AUC=0.777, p=0.000l) for identifying a sputum eosinophil count Methods. This retrospective study was conducted in
≥3%. Using logistic regression analysis, a threshold 295 patients with asthma aged 15–84 years recruited of 42 ppb was found to discriminate between from the asthma clinic of University Hospital of Liege.
eosinophilic and non-eosinophilic asthma Receiver-operating characteristic (ROC) curve and (p<0.0001). Patients receiving high doses of ICS (≥1000 μg beclometasone) had a significantly lower logistic model, FeNO (p<0.0001), high-dose ICS FeNO threshold (27 ppb) than the rest of the group (p<0.05) and smoking (p<0.05) were independent (48 ppb, p<0.05). Atopy also significantly altered the predictors of sputum eosinophilia, while there was a threshold (49 ppb for atopic vs 30 ppb for non-atopic trend for atopy (p=0.086).
patients, p<0.05) and there was a trend for a lower threshold in smokers (27 ppb) compared with non- Conclusion. FeNO is able to identify a sputum
smokers (46 ppb, p=0.066). Age and sex did not affect eosinophil count ≥3% with reasonable accuracy and the relationship between FeNO and sputum thresholds which vary according to dose of ICS, eosinophilia. When combining all variables into the smoking and atopy.
Categorization and Impact of Pulmonary Hypertension in Patients with
Michael J. Cuttica, Ravi Kalhan, Oksana A. Shlobin, Shahzad Ahmad, Mark Gladwin,
Roberto F. Machado, Scott D. Barnett, Steven D. Nathan
Respiratory Medicine 2010;104:1877-1822 Introduction. The functional significance of
those with normal hemodynamics. Normal pulmonary hypertension (PH) in COPD is unclear.
hemodynamics group: 261 ± 104m, PH; 238 ± 106m The purpose of the study was to define the (p<0.01), PVH: 228 ± 104m (p < 0.05). In a prevalence, severity and associated functional impact multivariable analysis, the mean pulmonary artery of PH in patients with severe COPD listed for lung pressure (β = -1.33; p = 0.01) was an independent predictor of a reduced 6MWD, as were forced Methods. A retrospective review of the Organ
vital capacity (β = 1.48; p < 0.001) and patient age Procurement and Tissue Network (OPTN) database (β = -1.91; p < 0.001). Both PH (HR 1.23 95%CI [1.01- between 1997 and 2006 for patients with the primary 1.50]) and PVH (HR 1.35 95%CI [1.11-1.65]) were diagnosis of COPD. Baseline demographics, hemo- shown to be independent risk factors for mortality on dynamics, pulmonary function tests, six minute walk the waiting list, even after adjustment for age sex, distance test (6MWD) and pre-transplant survival race, BMI, lung function, severity of illness and data was analyzed.
diabetes (PH: HR 1.27; 95% CI [1.04-1.55), PVH: HR 1.40; 95% CI [1.13-1.73]).
Results. 4930 patients with COPD had evaluable
right heart catheterization data (RHC). PH was Conclusion. PH is common in advanced COPD and is
present in 30.4%, with pulmonary venous associated with functional impairment and an increased hypertension (PVH) accounting for an additional mortality risk. Stratification by RHC determined 17.2% of patients. Patients with pulmonary pulmonary hemodynamics appears important in hypertension walked an average of 28 m less than distinguishing distinct clinical phenotypes.
Genetic Influences on Chronic Obstructive Pulmonary Disease—A Twin Study
Truls Ingebrigtsen, Simon F. Thomsen, Jorgen Vestbo, Sophie van der Sluis, Kirsten O. Kyvik,
Edwin K. Silverman, Magnus Svartengren, Vibeke Backer
Respiratory Medicine 2010;104;1890-1895 Background. Genes that contribute to the risk of
20-71 years of age. The analyses were replicated in a developing Chronic Obstructive Pulmonary Disease population of 27,668 Swedish twin pairs, 45-108 (COPD) have been identified, but an attempt to years of age. A Cox-regression model was applied to accurately quantify the total genetic contribution to the discordant time from the age at first hospital COPD has to our knowledge never been conducted.
admission for COPD in the co-twin of an affected Methods. Hospital discharge diagnoses data on
twin. Latent factor models were used to estimate COPD were analysed in 22,422 Danish twin pairs, genetic and environmental effects.
The Indian Journal of Chest Diseases & Allied Sciences
Results. The probandwise concordance rate for COPD
twins. According to the most parsimonious model, was higher in monozygotic (MZ) than in dizygotic additive genetic factors explained 63% (46-77%) of the (DZ) twins, 0.19 vs. 0.07 (p = 0.08) in the Danish individual COPD-susceptibility in the Danish population, and 0.20 vs. 0.08 (p = 0.006) in the population and 61% (48-72%) in the Swedish Swedish population. After adjusting for sex, smoking and age at first hospital admission the risk of Conclusion. The susceptibility to develop severe
developing COPD in the co-twin of an affected twin COPD, as defined by hospitalizations, is strongly was higher in MZ than in DZ twins, with hazards influenced by genetic factors. Approximately 60% of ratio 4.3 (95% confidence interval 1.2-15.8, p = 0.03) in the individual susceptibility can be explained by Danish twins and 3.4 (1.5-7.7, p = 0.004) in Swedish genetic factors.
Integrating Tobacco Cessation into Mental Health Care for Posttraumatic
Stress Disorder: A Randomized Controlled Trial
Miles McFall, Andrew J. Saxon, Carol A. Malte, Bruce Chow, Sara Bailey, Dewleen G. Baker,
Jean C. Beckham, Kathy D. Boardman, Timothy P. Carmody, Anne M. Joseph, Mark W. Smith,
Mei-Chiung Shih, Ying Lu, Mark Holodniy, Philip W. Lavori, for the CSP 519 Study Team
Context. Most smokers with mental illness do not
PTSD Checklist and Patient Health Questionnaire 9, receive tobacco cessation treatment.
respectively, to determine if IC participation or Objective. To determine whether integrating smoking
quitting smoking worsened psychiatric status.
cessation treatment into mental health care for Results. Integrated care was better than SCC on
veterans with posttraumatic stress disorder (PTSD) prolonged abstinence (8.9% vs 4.5%; adjusted odds improves long-tem smoking abstinence rates.
ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; Design, Setting and Patients. A randomized
P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence controlled trial of 943 smokers with military-related (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and PTSD who were recruited from outpatient PTSD remained significant at 18 months (86/472 [18.2%] vs clinics at 10 Veterans Affairs medical centers and 51/471 [10.8%], P <.001). Number of counseling followed up for 18 to 48 months between November sessions received and days of cessation medication 2004 and July 2009.
used explained 39.1% of the treatment effect. Between Intervention. Smoking cessation treatment integrated
baseline and 18 months, psychiatric status did not within mental health care for PTSD delivered by differ between treatment conditions. Posttraumatic mental health clinicians (integrated care [IC]) vs stress disorder symptoms for quitters and nonquitters referral to Veterans affairs smoking cessation clinics improved. Nonquitters worsened slightly on the (SCC). Patients received smoking cessation treatment Patient Health Questionnaire 9 relative to quitters with 3 months of study enrollment.
(differences ranged between 0.4 and 2.1, P = .03), Main Outcome Measures. Smoking outcomes
whose scores did not change over time.
included 12-month bioverified prolonged abstinence Conclusion. Among smoker with military-related
(primary outcome) and 7- and 30-day point PTSD, integrating smoking cessation treatment into prevalence abstinence assessed at 3-month intervals.
mental health care compared with referral to Amount of smoking cessation medications and specialized cessation treatment resulted in greater counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the The Indian Journal of Chest Diseases & Allied Sciences
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Copyright ©1999 by Jim Shull All photographs by the author. All rights reserved. Amherst Media, Inc. Buffalo, N.Y. 14226 Fax: 716-874-4508 Publisher: Craig Alesse Senior Editor/Project Manager: Richard Lynch Associate Editor: Michelle Perkins ISBN: 0-936262-70-2 Library of Congress Card Catalog Number: 98-71750 Printed in the United States of America.