What is generic Cialis? This is the first question one must ask before making any conclusions. Generic Cialis is a pharmaceutical copy of Cialis that is no different from the original branded medication. This means that Generic Cialis is cheaper than branded versions but made based on the same formula and with the same ingredients.

In order to understand how Cialis works, we need to know what Cialis is. In essence, this is a medication based on Tadalafil which is another phosphodiesterase type 5 inhibitor just like sildenafil which is the core ingredient of Viagra. Tadalafil is a one of the most efficient PDE5 inhibitors known to science and is used to treat various health issues related to arterial hypertension. At the same time, it is widely used to treat erectile dysfunction especially coupled with benign prostatic hyperplasia.

The Core Differences between Generic Cialis and Generic Viagra

One of the core differences between Generic Cialis and Generic Viagra is price. In the vast majority of cases, tadalafil based medications cost twice as much as sildenafil. The more sophisticated production process and arguably better effectiveness of tadalafil make its price higher than that of Viagra. The price difference is completely justified.

Many use a term “Weekend Pill” when referring to Cialis. The reason is that Tadalafil has a longer period of effective presence in the organism compared to other PDE5 inhibitors. The difference is quite substantial. For comparison, sildenafil half-life period in the body is roughly 5 hours at maximum. On the other hand, tadalafil lasts for up to 18 hours and has a persistent effect during this time span. Due to this difference and longer effectiveness, people refer to Cialis as a “weekend pill”.

Pharmacodynamics of the medication is similar to that of Viagra. The erection is achieved after increasing the amount of cGMP (cyclic guanosine monophosphate) which drastically changes the biochemistry and releases much more nitric oxide in order to make penile arteries and muscles nearby relaxed and ready for the blood stream. This allows blood to fill the vessels in Penis and erection occurs.

Tadalafil does not work without direct sexual stimulation. The whole process of erection is based on the instinctive response of penile tissues to direct stimulation.

All PDE5 inhibitors works alike and serve to the same purpose. As mentioned above, the main difference between Tadalafil and Sildenafil is the time of effect. Scientists worked for a long time to synthesize a PDE5 inhibitor that would last longer in the organism and Tadalafil is one of the most efficient findings so far.

The Impact of Tadalafil


The marketing team behind Viagra is a lucky one. Back then, the competition for Viagra was fairly limited and many other medications were highly ineffective with some direct competitors showing the success rate lesser than 40%. Sildenafil based medications showed an incredible 80% success rate and kept showing spectacular results in the period after marketing.

Cialis entered the market when it was occupied by branded Viagra. This is why many people have heard about Viagra, but may not even know about the very existence of Generic Cialis which is arguably even more effective than Viagra. The difference in effectiveness shows in how long the effect lasts. Viagra requires men to take several pills in case they plan sexual activities over the course of two or more days. In many cases, taking a single pill of generic Cialis may seal the deal.

Tadalafil definitely improved the situation in the market by creating more versatility both in terms of price and utility. Those people who need short-term solutions for their erectile dysfunction may choose Viagra as a cheaper option with a short-term effect. Seeking for a more powerful and more expensive solution will choose Cialis instead. This is a better market environment that allows men to choose the best option for their specific issues.

To follow through, here are the best offers on brand Cialis and Generic Cialis among Canadian and US online pharmacies:

  • accessrx.com – $86.00  per pill (brand Cialis)
  • kwikmed.com – $43.30 per pill (brand Cialis)
  • canadadrugs.com – $24.40 per pill (brand Cialis)
  • mycanadianpharmacypro.com – $1.43 per pill (generic Cialis)
  • northwestpharmacy.com – $20 per pill and price for generic Cialis $9.5 per pill

As you can see, My Canadian Pharmacy actually offers one of the best offers on the market. Of course, you can pay over for the brand pill at Accessrx or Canadadrugs, if you still have trust issues with generics, but based on customer reviews, the quality of generic Cialis from My canadian pharmacy is just fine.

Generic Cialis is cheaper than branded versions and have the same effect. This made the medication more affordable and allowed more men to use it for treating erectile dysfunction.

Side effects and known issues with Generic Cialis

In essence, tadalafil is still another PDE5 inhibitor even if it lasts longer than other PDE5 inhibitors. This means that Cialis shares side effects and problems with sildenafil or vardenafil. After the marketing, the sample size of studies was drastically expanded. Over 8 million customers have tried Cialis after it was released worldwide and more than 15 thousand participants of preliminary tests were also carefully studied.

Most of the side effects are harmless and disappear after a few hours. These symptoms are common for PDE5 inhibitors and caused by the expansion of blood vessels caused by unexpectedly high rate of NO generation in the organism. This effect can be reduced by adjusting the intake of tadalafil. If certain side effects occur, reducing the dose is one of the most straight-forward and effective solutions.

The list of most commonly occurring side effects include discomfort in abdomen, aches in back, muscle pains, minor issues with digestion, and stuffy nose. Many symptoms have a very short lasting nature. However, muscle and back pains may occur later and last longer, up to 2 days. Note that many symptoms may be more frequent or harmful due to physiological specifics of individuals. For example, people with weaker vascular systems may suffer from a wider list of more severe side effects.

While the prescription for tadalafil is not required to make a purchase online, consulting a doctor is a good idea in order to ensure that you can take PDE5 inhibitors without any risk for your health.

One of the problems discovered during the after-marketing period was unexpected temporary hearing loss. This happened only several times and has a very small occurrence rate, but still needs to be taken into consideration when choosing the best medication for treating erectile dysfunction.

Tadalafil and other drugs

This issue is common for both tadalafil and sildenafil. As mentioned above, both generic Cialis and Viagra are essentially PDE5 inhibitors and thus share many disadvantages and advantages characteristic for this type of medications. One of the biggest concerns that should be on the mind of a person who wants to try out any PDE5 inhibitor is low blood pressure caused by the intake of tadalafil. The risk of hypotension is further increased with the intake of other supplementary sex drugs that are based on various organic nitrites. It is highly recommended to take nitrates in order to normalize the blood pressure.

There may be other issues with simultaneous intake of Generic Cialis with other drugs especially those that directly affect blood vessel system and blood circulation. Another important issue is that using PDE5 inhibitors without nitrates to neutralize their effect right after usage is a potential risk factor that should be considered by anyone who wants to treat erectile dysfunction with Generic Cialis.


In many ways, Generic Cialis is similar to Viagra. Both drugs are based on PDE5 inhibitors and work alike. However, tadalafil in Cialis is a long-lasting compound that has an arguably better effect compared to sildenafil in Viagra. Another important difference is the price since Generic Cialis usually priced higher than Generic Viagra. Ultimately, the choice between two drugs should be made based on individual specificities of the organism and personal preferences.

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Erectile Dysfunction is a big problem of modern society mostly due to the fact that no one is safe from this life-ruining health issue. The origins of the problem may differ from case to case. Ranging from physiological causes to a plethora of psychological. There are various environmental issues in this world and many have a direct impact on erectile function.

Bad ecology, stressful schedules, and unhealthy style of living make problems with erections far more frequent than they should be. Now, we all live in a very stressful and far from ideal environment. We have to deal with a multitude of stress sources and constantly struggle with fencing off the negative impact of environment. Additionally, smoking (even passive) and drinking alcohol may cause early erectile dysfunction. Another factor is age. The older we get, the harder it is to maintain erection as long as we would like it.

Due to the wide-spread of the problem, the very problem of treating erectile dysfunction is one of the priorities in modern medicine. Note that treating the core issue is often troublesome and many focus on inhibiting symptoms. Erectile dysfunction is also just a manifestation of a disease or health issues. However, this manifestation is something that needs immediate attention and can be cured fairly easily.

We recommend for read full information about Erectile Dysfunction: http://www.medicalnewstoday.com/articles/5702.php

Viagra. The New Age Miracle

ED Treatment

When the brand of Viagra appeared, the male population of the world rejoiced. This was a simple and conventional solution for the problem that millions were looking for. While not many men are suffering from a complete loss of erectile function, hundreds of thousands experience temporary and infrequent problems with erection. In the vast majority of such cases, men are not really sure if they need medical attention and would prefer to keep the problem away from the public eye.

Viagra was a very efficient and all-around good solution due to a plethora of reasons:

  • Buying without a prescription. Getting a prescription means discussing the problem with a doctor. For many men this is a big red “no”. Some people are simply not comfortable with discussing their health issues with strangers. Doctors, however caring and professional they may sound, are total strangers and make us uncomfortable. Viagra can be bought online without a prescription.
  • Convenient usage. When it comes to Viagra Professional, one does not have to worry about the method of intake. Just swallow a pill and the desired effect comes shortly after. It is simple and it does not cause any troubles.

However, branded versions of Viagra were priced highly and were out of reach for average men. Even those who could afford buying it were limited in terms of usage. This issue was recently removed from the table. Many brands of Viagra professional are competing against each other creating a healthy market with a multitude of competitors who equalized the market and made the median price much lower than it was before.

Does it really work?

Many consumers are concerned with the effectiveness of Viagra professional. Obviously, some are not certain that a single medication can completely carry away erectile dysfunction. However, clinical studies and years of studies in the after-marketing period showed that Viagra and Viagra professional are showing impressive success rate of 80%. Yes, in 8 out of 10 cases the result is positive. The remaining 20% experience slight problems with erection. Note that Viagra professional has a success rate of 92%.

Simultaneously, many people are concerned with possible side effects. Again, years of research did not find any critical side effects and many side effects are common for the vast majority of completely safe and widely used medications.

Viagra professional is a slightly more powerful version of Viagra. However, it does not require specific consultations with doctors and can be used without prescriptions. Note that choosing the right dosage and proper time frames for usage are individual matters. Every single person has to adjust the intake based on his personal experiences. At the same time, various brands of Viagra professional may yield different results and each time you choose a new brand, you have to adjust your intake habits.

Problems and known issues

Viagra professional should be taken with other types of medications after consultations with doctors. There are cases when even a small intake of phosphodiesterase type 5 inhibitor may cause health issues when coupled with other medications. This relates to any type of medication and not only Viagra. If you have to combine various types of medications, make sure that they are compatible and do not cause any troubles for your organism when taken simultaneously.

The effect of Viagra professional may be less visible and be slower if taken with meals containing fat. High-fats, red meats, and other similar products may significantly inhibit the effect of Viagra. Oftentimes, such diet may slow down the effect, but will still impact erectile function positively. Note that when balancing your diet while using Viagra.

Now, some people report that they have troubles with erection even after taking a pill of Viagra. Frequently, this occurs when men expect erection without sexual stimulation. Note that without sexual stimulation and psychological arouse it is hard to achieve healthy erection even with an enormously big dose of Viagra.

Continuous treatment of Erectile Dysfunction

Regular intakes of Viagra may improve erectile function. In the vast majority of cases, regularly scheduled intakes of Viagra yield better results in the long run. However, if you want to engage in sexual activity, you need to take a pill before the engagement.

Calculating a healthy dosage is a complicated matter. You may want to consult with a specialist who will help you with developing an efficient treatment course. This also helps you to estimate the amount of Viagra professional required for treating erectile dysfunction in the long run.

Note that Viagra also helps your organism in many ways. On top of dealing with erectile dysfunction, Viagra professional helps in normalizing a plethora of other body mechanisms including:

  • Problems with bloodstream and blood vessel system in general. Also helps in normalizing and treating nervous system to a certain degree.
  • Blood circulation in the whole body and body zones related to erectile function. This makes organism healthier in many aspects.
  • Treating diabetes symptoms. Erectile dysfunction is one of the manifestations of diabetes and regular intakes of Viagra professional can minimize the effect of this disease.

Purchasing Viagra Professional Online

One of the best things about Viagra professional is that you can purchase it online without having to worry about personally talking to a pharmacist. Ordering a pack of Viagra professional is simple and convenient and you can do it sitting in your favorite chair. The prices are much lower than in regular local stores and you can always search for the best option.

At the same time, ordering online has a very important benefit of complete anonymity. You can make an order without being afraid that someone will find out about your purchase. The delivery is usually completely anonymous as well with the package being absolutely neutral.

Again, you don’t need a prescription or any other documents in order to make a purchase online. This is absolutely legal and safe. Make sure to follow the recommendations provided by the manufacturer in order to avoid health issues.

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Nearly 80% of the dispensed medications are generic ones. Being absolutely identical to their branded equivalents these are substantially cheaper which implies pretty large savings (up to two-thirds) without sacrificing quality and safety. Quite a big segment of this part in its turn is taken by generic medications used for treatment of erectile dysfunction. They are among the most sought and ordered medicines and not only in Canadian Pharmacy so let’s get some facts about generic medications in general and why purchase them at this very drugstore in particular.

What Are Generic ED Medications? Quality and Safe ED Medications in Canadian Pharmacy

These are the same basic products as the brand-name ones. This means that they can be taken for the same reason and in the same way. They are also identical in the following: active ingredient, form of dosage, strength and efficacy.

All the rest like shape, color, packaging and sometimes flavor and preservative is different which is actually a copyright issue. However, there is one more difference so much discussed and talked about – difference in price where any generic ED medication like e.g. Canadian generic Viagra can cost ten times cheaper than its branded equivalent.

Why Is the Difference in Price so Substantial?

Unlike brand-name manufacturers generic ones don’t have to spend funds on research and large-scale drug testing as well as marketing, advertising and promotion where the latter factors can cover far more of overall expenditure than the first two ones. Purchasing any generic ED medication you pay for the drug per se and not its patent. Now men are not only well aware of these peculiarities but most have already tried out the offered non-proprietary ED drugs, so cannot figure out why they should pay more if the same effect can be achieved when taking cheaper medications of the same quality and safety.

Why Purchase ED Medications from Canada Pharmacy

Like one of the most reliable and popular online drugstores http://www.canadianhealthcaremalll.com dispenses only high quality, safe and certainly effective drugs against erectile dysfunction. What you as a customer should also know about the pharmacy is the following:

1. The drugstore cooperates only with highly regarded and time-tested suppliers all of which are FDA approved manufacturers.

2. Due to this direct cooperation as well as the matter that the drugstore spends nothing on marketing all ED medications are decently priced products. This is manufacturing cost only what is charged.

3. Depending on your order you will be provided with either free bonus pills (usually four) or with both free pills and free insurance; the latter ensures order reshipment in case of delivery failure. Free Regular Airmail is another special offer provided.

4. Your confidentiality, anonymity and discreetness are pharmacy’s major concern. To ensure proper protection of your personal data 256 bit encryption is used.

5. Finally, you’re welcome to get personalized professional help (if you need any) as well as top-notch customer support.


Screening: general concerns
No clear consensus exists across medical specialties with respect to the benefits of PSA screening in the general population. The American Urological Association and the American Cancer Society recommend annual PSA and DRE screening for men stardng at 50 years old (40 or 45 in high-risk patients); the American College of Preventive Medicine and the American College of Physicians-American Society of Internal Medicine, on the other hand, do not. Survey data across three US states of practices by generalists and internists suggest that only 67% of family physicians and 40% of internists routinely screen men over 50.

The presence of LUTS does not predict prostate cancer incidence, but it does increase the likelihood of PSA testing, as do a diagnosis of Benign Prostatic Hypertrophy (BPH) and/or prior history of prostate surgery. BPH patients are also, of course, more likely to be seen by a urologist; a 1997 Gallup survey found that 92% of urologists employed routine PSA testing among their BPH patients. The Agency for Health Care Policy and Research and the International Consultation on BPH both recommend PSA measurement in those BPH patients for whom an incidental diagnosis of prostate cancer would spur a change in management (generally referring to patients with at least a 10-year life expectancy).
Prostate cancer detected incidentally during work-up or surgery for BPH may not necessarily be clinically significant. In the series of Tombal and colleagues, 8% of T1a patients opting for surveillance progressed at a mean of 73 months, whereas 29% of T1b patients progressed at a mean of 17 months. Kearse and associates followed 304 TURP patients for a minimum of 8 years, concluding that the risk of progression and death among T1a prostate cancer patients was not significantly elevated over those confirmed to have only BPH on pathological examination. Epstein and coworkers found, conversely, that even low-volume T1a tumors may progress and cause mortality with extended follow-up. Fowler and colleagues also point out that, with the decline in surgical management for BPH, men with T1a/b prostate cancer are increasingly likely to be undiagnosed.

A fundamental caveat with respect to interpretation of studies of diagnostic tests’ predictive ability is raised periodically in reviews of the prostate cancer screening literature and should be reiterated here: most studies report sensitivity (i.e. the proportion of cancers that will be diagnosed) and specificity (i.e. the proportion of unnecessary biopsies that may be avoided) of a test in a given population, and frequently present receiver operating characteristic (ROC) curve areas as a means of comparing competing tests. The calculation of these measures, however, is highly dependent on the prevalence among the study population of the disease in question. Thus, if a test’s threshold value is calculated to yield high sensitivity among a referral population in whom prostate cancer is relatively common, in a general screening population the same test would retain high sensitivity but may have very low specificity.

For this reason, the positive and negative predictive values (PPV and NPV) of a test, reported less frequently, are more relevant to most clinical decision-making. For ROC comparisons among unfractionated PSA and other assays between prostate cancer and BPH patients, Jung and colleagues have suggested matching patients by unfractionated PSA, to compensate for unequal distribution of PSA values between the two groups, but such adjustments are not usually performed.

More information and facts about PSA and DRE screening and prostate cancer, you can found in the site – www.acanadianhealthcaremall.com.

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This exercise is particularly healing for those who insist “I can’t draw’’ and “I’m a terrible artist.’’ If you hear negative comments regarding your work, remember that’s not you, it’s a member of the Committee, intent on sabotaging your effort. Now spend a few minutes with what you’ve done. Notice how you feel as you look at your work. If there’s anything that you find powerful, surprising, or interesting, take some time out and write about it in your journal. In the next chapter you will continue working with this image to Undo it.




By now, you have begun to create a different relationship with asthma symptoms. Instead of just trying to get rid of the symptom, as in conventional Western medicine, you are learning how to Focus on the symptom’s meaning and message. For, until we listen to the message of the symptom, it continues to repeat itself in one form or another. If you hold a belief that physical symptoms have no meaning besides your bodily discomfort, we suggest you suspend this way of thinking. Your Committee will be more than glad to hold onto it for you until you decide you want it back.

When you listen without analyzing or drawing conclusions, symptoms reveal themselves. A symptom may speak to you during an imagery exercise, while writing in your journal, in a dream, or as a spontaneous insight that seems to come out of nowhere. This next section describes how Focusing through breathing, singing, and a unique exercise called the Breathometer (pronounced like barometer or thermometer) can shift your relationship to your symptoms and empower you to live joyfully and breathe freely.

BreathWorks: Singing, Breathing, and Healing

How often do you fully release your breath? When, if ever, do you sing out with joy and let go of sadness and pent-up emotions? How important is the relationship of letting go to breathing? And what can singing offer in the process of channeling both breath and emotion?

On a video produced by the Carl Stough Institute of Breathing Coordination,Lauren Flanigan, an operatic soprano and an asthmatic, describes her symptoms as claustrophobic. Claustrophobia involves a fear of being closed in, confined in a narrow space. It is the phobic concomitant of an asthma symptom. In Flanigan’s case, her claustrophobic symptoms mirrored the torment of her emotional confinement to grief. Even the music she chose involved sadness, grieving, and loss. Chinese medicine sees grief as an important sign of “internal cold,” which affects both the lungs and the adrenal glands. Grief makes it harder for us to breathe — it’s what we “hold” in our chest or gut.

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I have recently been given steroid treatment (prednisolone) for severe arthritis. My joints are better but my doctor has now found sugar in my urine and tells me I have diabetes. Is this likely to be permanent?

Steroids are effective treatment for a number of conditions but they may cause side effects. One of these is to cause diabetes, which can sometimes be controlled with tablets (e.g. gliclazide). If large doses of steroids are being used, people often need insulin to keep the blood glucose under control. When you stop steroid therapy, there is a good chance that the diabetes will disappear.

However, you may have had diabetes without knowing it before you started on steroids, in which case you will still have diabetes after stopping steroids and will need to continue some form of treatment indefinitely.

I am told that other hormones that the body produces may cause diabetes. Is this true?

Diabetes occurs when there is not enough insulin for the body’s needs.

Sometimes excessive amounts of other hormones will tend to push up the blood sugar levels. If the body cannot respond with enough extra insulin, diabetes may result. Thus someone who produces too much thyroid hormone (‘thyrotoxicosis’ or ‘hyperthyroidism’) may develop diabetes, which goes away when their thyroid is restored to normal. Thyrotoxicosis and diabetes tend to run together in families, and people with one of these conditions are more likely to develop the other.

Sometimes a person will produce excessive quantities of steroid hormones (Cushing’s disease or Cushing’s syndrome), and this may lead to diabetes (see the previous two questions for the connection between steroids and diabetes). Acromegaly is a condition where excess quantities of growth hormone are produced and this too may lead to diabetes.

I have had to go to hospital for repeated attacks of pancreatitis and now have diabetes. I am told that these two conditions are related – is this true?

Pancreatitis can be a very painful and unpleasant illness: it means that your pancreas has become inflamed. The pancreas is the gland that produces insulin as well as other hormones and digestive juices. If it is severely inflamed or damaged, it may not be able to produce enough insulin. Sometimes diabetes develops during or after an attack of pancreatitis and tablets or insulin are needed to keep control of the blood glucose. This form of diabetes is usually, but not always, permanent.

What other diseases would increase the chances of getting diabetes?

There are three groups of such diseases:

  • Glandular disorders, in particular thyrotoxicosis (overactive thyroid), acromegaly (excess growth hormone) and Cushing’s disease (excess steroid hormone, see above); polycystic ovary syndrome and fatty liver disease are both linked with insulin resistance and therefore carry an increased risk of Type 2 diabetes;
  • Diseases of the pancreas, including pancreatitis, cancer of the pancreas, iron overload (haemochromatosis) and cystic fibrosis (a serious inherited childhood disorder); surgical removal of the pancreas (for either pancreatitis or cancer) also causes diabetes;
  • Medical problems, such as heart attacks, pneumonia and major surgical operations which put stress on the body: the diabetes usually clears up when the stress is removed but these individuals may be more at risk of diabetes in the future.


Where or how do I find out about the carbohydrate or calorie content of foods? Treatment without insulin

There are many publications giving this information which are available in newsagents and bookshops. If you have access to the internet then a search will give you a great number of options. If you do not have access to the internet, your local library or Diabetes UKCareline may be able to help.

Another source of information is the nutritional labels on the foods you buy. If you find food labels difficult to understand then your dietitian will be able to explain how to use this information.

The guidelines are based on what an average person may have when eating a balanced diet. They are not therefore suitable targets for everyone. Individual requirements vary according to weight and activity level.

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It must be noted that the figures are per 100 g of a food and each food choice should be taken in context of how much of it you eat and how often you eat it. No food needs to be excluded from an eating plan, but you should try and make sensible choices.

Many supermarkets have introduced labelling in traffic light colours (red, amber, green) to provide consumers with guidance on how healthy the food might be – green being the most healthy option.

I have just started tablets for my diabetes. Does this mean I can relax my diet?

You have been started on tablets for your diabetes because diet alone has not been enough to keep your blood glucose at a desirable level. Tablets are not a substitute for your diet but are an additional help, so it is very important that you maintain your efforts with your diet and with exercise. If you relax your diet then your blood glucose will be more difficult to control and your medication may have to be increased prematurely in order to counteract your relaxed diet. This may also lead to weight gain. If it has been a while since you have seen a dietitian, it may help to make an appointment to review your food plan, now that you are on tablets, to discuss any other changes that you could make.

How does a person with diabetes get an appointment with a dietitian? Will there be one at my doctor’s?

As diet plays a crucial part in the management of diabetes, it is important that you get sound expert dietary advice from a State Registered Dietitian. This is part of the recommended standard of care as detailed in the Diabetes UK booklet What diabetes care to expect.

The availability of dietitians varies across the country but most diabetes centres have a dietitian as part of their diabetes team. If you attend a hospital diabetes centre then you should be able to make an appointment with the dietitian. There are an increasing number of GP practices running local diabetes clinics and they should be able to arrange an appointment with a dietitian as part of your diabetes care.


On January 1, 1999, all adult critically ill patients were moved to new and larger SICU and MICU facilities. The rate of nosocomial infections was calculated before and after the introduction of the AIC as an intervention for the time periods that preceded the move. On August 1, 1998, the AICs were introduced to the MICU and SICU. In the old unit, the rate of nosocomial BSIs decreased from 6.8 per 1,000 patient-days prior to the introduction of the AICs (ie, September 1, 1997, to July 31, 1998) to 1.9 per 1,000 patient-days after their introduction (ie, August 1 to December 31, 1998) [p < 0.001]. Similarly, the rate of documented catheter-related infections decreased from 3.4 per 1,000 patient days to 0.2 per 1,000 patient-days (p = 0.003) during the two time periods described above. In addition, the rate of nosocomial Gram-positive BSIs significantly decreased during the same time periods (p < 0.01) and tended to decrease for nosocomial Gram-negative BSIs (p = 0.06).

Most of the nosocomial primary BSIs were caused by Gram-positive organisms. When calculated in terms of 1,000 patient-days, there was a significant decrease in nosocomial Gram-positive BSIs from FY 1998 to FY 1999. For specific Gram-positive organisms, there was a significant decrease in the rate of nosocomial BSIs independently for VRE infections, coagulase-negative staphylococci, and vancomycin-sensitive enterococci (p < 0.05). In addition, the rate of nosocomial BSIs caused by Gram-negative bacillary organisms tended to decrease from 1 per 1,000 patient-days in FY 1998 to 0.2 per 1,000 patient-days in FY 1999 (p = 0 0.06). Within the limitations of small numbers, there was no significant decrease in the frequency of Pseudomonas aeruginosa infections or Candida infections for the two time periods. In three of eight (38%) of the nosocomial VRE bacteremias diagnosed in FY 1998, the catheter was documented as the source of the BSI.

Seven of the eight VRE isolates were available for susceptibility testing. Five of the seven isolates were susceptible to minocycline (MIC, < 2 g/mL). There were two additional VRE bacteremic isolates, one of which was resistant to minocycline (MIC, 8 g/mL) but was highly susceptible to rifampin (MIC, < 0.06 g/mL). The other VRE bacteremic isolate had intermediate susceptibility to minocycline (MIC, 4 g/mL) but was highly resistant to rifampin (MIC, > 128 g/mL) Tretinoin cream Canada. Hence, six of the seven isolates were susceptible either to minocycline or rifampin, and therefore, the catheters impregnated with minocycline and rifampin had a zone of inhibition of > 11 mm against these same isolates.


Conclusion: CT findings of parenchymal fibrosis are associated with reduced survival in patients with HP and may serve as a useful prognostic indicator.

Key words: CT; hypersensitivity pneumonitis; prognosis; pulmonary fibrosis Abbreviations: HP = hypersensitivity pneumonitis; HRCT = high-resolution CT

Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is an immunologically induced inflammatory disease involving the lung parenchyma and terminal airways secondary to repeated inhalation of an inciting agent in a sensitized host. The inciting agent may be derived from a wide variety of fungal, bacterial, animal, or chemical sources. Three clinical presentations are generally recognized: acute, subacute, and chronic. The clinical course associated with HP is variable. With early diagnosis and avoidance of the offending antigen, the prognosis tends to be favorable and permanent respiratory impairment can be avoided. However, chronic forms of HP may be complicated by development of pulmonary fibrosis and progressive respiratory insufficiency.

Histopathologic evidence of fibrosis on surgical lung biopsy has been associated with reduced survival in patients with HP and allows for identification of patients at higher risk of mortality. However, surgical lung biopsy is not commonly employed in the diagnosis of HP. In contrast, high-resolution CT (HRCT) is routinely obtained in the course of evaluating patients with interstitial lung diseases. HRCT features of HP are well recognized and include a spectrum of abnor-malities. In this study, we sought to correlate HRCT evidence of parenchymal fibrosis with survival in a consecutive series of patients with HP seen at our tertiary care medical center.

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Study was conducted at a university-affiliated, urban teaching hospital, Barnes-Jewish Hospital (1,400 beds). During a 20-month period (ie, February 2000 to October 2001), all patients requiring admission to the medical ICU (19 beds) for 48 h were eligible for this investigation. This inclusion criterion was prospectively selected to minimize the enrollment of patients with rapidly fatal illnesses and self-limited conditions not requiring more prolonged intensive care. Patients were excluded from this investigation if they had transferred from another hospital, if they had undergone a bone marrow transplant, or if they had been temporally transferred to the medical unit from another ICU due to staffing issues. The medical ICU is a closed unit with a multidisciplinary team providing patient care under the direction of attending physicians who are board-certified in critical care medicine.

For all study patients, the following characteristics were prospectively recorded by one of the investigators: age; gender; race; severity of illness based on APACHE (acute physiology and chronic health evaluation) II scores; and the presence of congestive heart failure, COPD, underlying malignancy, recent chemotherapy, seropositivity for HIV, diabetes mellitus, chronic renal insufficiency, cirrhosis, and solid organ transplantation. Specific processes of medical care examined during patients’ intensive care stay included the following: administration of antacids, sucralfate, histamine type-2 receptor antagonists, or corticosteroids; the number of central venous catheters placed; enteral nutrition; mechanical ventilation; the need for reintubation; the placement of a tracheostomy; surgery prior to ICU admission; the use of vasopressors; and the adequacy of the initially prescribed antibiotics for microbiologically confirmed infections. Infection variables also were examined, including leukocytosis, the development of new radiographic lung infiltrates, the presence of purulent sputum, temperature > 38.3°C, the presence of severe sepsis, the presence of Clostridium difficile infection, bloodstream infection Sildenafil citrate Australia , ventilator-associated pneumonia, hospital- acquired pneumonia in patients not requiring mechanical ventilation, tracheobronchitis, urinary tract infection, skin and soft-tissue infection, and community-acquired pneumonia; colonization with vancomycin-resistant enterococci; and the presence of multiple microbiologically confirmed infections.