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Immunodeficiency Clinic

Table 39 lists the pharmacological components of OMT. For practical purposes the mnemonic ‘ABCDE’ approach has been proposed: ‘A’ for antiplatelet therapy ( Table 36 ), anticoagulation, angiotensin-converting enzyme inhibition, or angiotensin receptor blockade; ‘β’ for β-blockade and blood pressure control; ‘C’ for cholesterol treatment and cigarette smoking cessation; ‘D’ for diabetes management and diet; and ‘E’ for exercise.

Table 39
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Long-term medical therapy after myocardial revascularization

Table 39
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Long-term medical therapy after myocardial revascularization

Table 36
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Antithrombotic treatment options in myocardial revascularization

Table 36
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Antithrombotic treatment options in myocardial revascularization

Cardiac rehabilitation and secondary prevention programmes are implemented in or out of hospital, according to the clinical status and the local facilities. A structured in-hospital (residential) cardiac rehabilitation programme, either in a hospital or in a dedicated centre, is ideal for high-risk patients, who may have persistent clinical, haemodynamic, or arrhythmic instability, or severe complications or comorbidities.

After uncomplicated PCI or CABG procedures, physical activity counselling can start the following day, and such patients can walk on the flat and up the stairs within a few days. After a revascularization procedure in patients with significant myocardial damage, physical rehabilitation should start after clinical stabilization.

The following general criteria should be considered in planning an exercise testing modality for exercise prescription: safety, i.e. stability of clinical, haemodynamic, and rhythmic parameters, ischaemic and angina threshold (in the case of incomplete revascularization), degree of LV impairment; associated factors (i.e. sedentary habits, orthopaedic limitations, occupational and recreational needs).

Although the need to detect restenosis has diminished in the DES era, a sizeable proportion of patients are still treated with BMS or balloon angioplasty with high recurrence rates. Likewise, the durability of CABG results has increased with the use of arterial grafts and ischaemia stems mainly from SVG attrition and/or progression of CAD in native vessels.

Follow-up strategies should focus not only on the detection of restenosis or graft occlusion, but also on the assessment of patients’ functional status and symptoms, as well as on secondary prevention. A baseline assessment of physical capacity is needed when entering a rehabilitation programme after revascularization [ 265 ].

In a later publication, Berry et al assessed prospectively whether a rapid PCR assay correlated well and reliably with clinical CDI diagnosis [ 190 ]. The GeneXpert C. difficile assay was compared with CCNA and a GDH/Toxin A/B EIA algorithm. Clinical diagnosis, adjudicated by an unblinded team of multidisciplinary experts, served as the reference for evaluation of the different test performances (>1000 PCR and CCNA tests were performed). Sixty-two patients were both PCR and CCNA positive and an additional 59 specimens were PCR positive alone, among which 54 (91.5%) were in patients clinically diagnosed as having CDI. When the GDH screen was evaluated, 16.2% of patients with clinical CDI would not have been detected. Combining GDH and EIA testing, 59.7% of patients with CDI would have been missed (GDH positive, toxin EIA negative). Patients who were CCNA positive/PCR positive had higher all-cause 30-day mortality compared with CCNA-negative/PCR-positive patients. This study only presented results obtained after repeat testing of indeterminate results. The claimed PPV of 91.9%, using clinical diagnosis as the reference, is much higher than found elsewhere [ 186 ]. Patients were not followed long term to assess other clinical outcomes.

In summary, if patients are screened carefully for clinical symptoms likely associated with CDI (at least 3 loose or unformed stools in ≤24 hours with history of antibiotic exposure), then a highly sensitive test such as a NAAT alone or multistep algorithm (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) may be best. A 2- or 3-stage approach increases the PPV vs one-stage testing.

The issue of if or when to retest for CDI is inherently linked to the accuracy of the employed routine testing method. Methods with suboptimal sensitivity for C. difficile (eg, stand-alone toxin EIAs) led to frequent retesting in some settings. Ironically, use of tests with suboptimal specificity means that multiple repeat testing runs a high risk that false-positive results could eventually be generated. Ideally, in the absence of clear changes to the clinical presentation of suspected CDI (ie, change in character of diarrhea or new supporting clinical evidence), repeat testing should not be performed. This advice is based on the above-mentioned issues and also on studies that have shown that the diagnostic yield of repeat testing within a 7-day period (with either toxin A/B EIA or NAAT) is approximately 2% [ 191 , 192 ]. Furthermore, use of highly sensitive testing strategies (eg, 2-stage algorithms or stand-alone NAATs) means that the single tests have very high negative predictive value (typically >99%) for CDI.

There may be more value of repeat testing in epidemic settings where CDI acquisition is more frequent [ 193 , 194 ]. For symptomatic patients with a high clinical suspicion of CDI but a negative CDI test, particularly those in whom symptoms worsen, repeat testing should be considered; this does not equate to routine retesting, given that the great majority of patients with suspected CDI do not have the disease.

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By Dean Schabner
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Americans work more than anyone in the industrialized world.

More than the English, more than the French, way more than the Germans or Norwegians. Even, recently, more than the Japanese.

And Americans take less vacation, work longer days, and retire later, too.

That much most people agree on. What's harder to pin down is exactly how much Americans are working. It may be more than our industrialized competitors, but is it more than we have ever worked before?

The short answer, according to the government, is that it is only slightly more and not so much that most people should really notice.

Numbers from the Bureau of Labor Statistics show a very gradually rising trend through the 1990s that has only just recently tapered off, hovering somewhere just north of 40 hours weekly.

A Month More a Year?

The long answer is, of course, more complicated. It depends who you ask, and about whom you're asking.

Author Juliet Schor, who wrote the best-selling book The Overworked American in 1992, concluded that in 1990 Americans worked an average of nearly one month more per year than in 1970.

There are also volumes of surveys that ask people if they're working more than they used to. Generally, people say yes, of course they are. And they also estimate almost 10 more hours a week than the government does.

A Bunch of Whiners?

Critics pooh-pooh such studies, saying self-estimators are exaggerators, although most of those studies echo the same general trend as governmental figures — a bit of a rise through the '90s with a slight dip recently.

Dissenters to overworked-American theories say it's better to base studies on employers' reports of worker hours, which is what the government does, but that leaves out overtime hours worked by salaried employees.

Critics also point to what they say is a growing number of part-time jobs. How can people be working more if they are not working full-time?

Here's where you have to ask which workers we're really talking about.

Measuring Past the Punch Clock

That's what Schor's book tries to do, as well as two recent releases: The White-Collar Sweatshop by Jill Andresky Fraser, and The Working Life by Joanne B. Ciulla.

All those books have been embraced by a large part of the public that apparently feels harassed by the pressures of the workplace.

The authors all find evidence that many Americans are overstressed and overworked in trends that are not necessarily measured with a punch clock; trends such as road rage, workplace shootings, the rising number of children in day care and increasing demands for after-school activities to occupy children whose parents are too busy or still at work.

They aren't the only ones finding long hours in at least certain parts of the workforce. According to a Bureau of Labor Statistics report released last year, more than 25 million Americans — 20.5 percent of the total workforce — reported they worked at least 49 hours a week in 1999. Eleven million of those said they worked more than 59 hours a week.

Sweat Under the White Collar

Who are these people? Fraser, after four years of interviews, concludes they are white-collar workers, who do not punch a clock and whose hours therefore are the most difficult to track.

The other evidence often pointed to that people are not really working as much as they say is the increasing number of part-time jobs. How can people be working more if more people are not working full-time?

But the anecdotal evidence presented by Fraser, Schor and Ciulla — and met by millions of people everyday — is that many Americans feel they are working more than ever.

An poll released Monday found only 26 percent of Americans feel they work too hard. Although far more feel the opposite, that's still a lot of people and it's twice as many as the 13 percent who told a Harris Poll in 1960 that they felt overworked. And the percentage rises to about a third of people with kids, or people between 35 and 54 years old.

What Happened to 'The Little Woman'?

Even for people who are not actually working longer hours than they used to, there's an explanation for why some of them might feel over-burdened anyway, particularly men.

Experts who accept some of the arguments of both sides of the working-longer debate often focus less on individuals' hours worked, instead looking at household hours on the job.

In Overworked and Underemployed, a study in The American Prospect, Barry Bluestone and Stephen Rose argue that to really understand the situation Americans face, you need to look beyond individuals and numbers.

The overall figures for how many hours a week the average American works have been held down by the increasing number of part-time service and retail jobs in the economy. But since many of the part-time jobs have been filled by the increasing number of women in the workforce, and many of these women had previously been housewives, there are fewer hours when anyone is taking care of household chores.

Instead of coming home to find the refrigerator and cupboards stocked, dinner ready, the table set, the clothes washed, the house clean and the children entertained, men are coming home and finding they have to chip in, because their wives aren't "the little woman," anymore. They are now sharing duties as breadwinner, which means men have to share household chores. The situation is exaggerated when both spouses work full-time — particularly if they don't earn enough to hire help.

If people aren't spending quite as many more hours at work as they think they are, the fact that they aren't allowed as much leisure time once they're off work might account for the apparent illusion.

Authors like Fraser, Schor and Ciullo, though, argue that there is no illusion, and the case made by the harried Americans who fill their books — and fill commuter trains and highways — is hard to discount.

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