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The thrust of the article is that branch of drugless healing he is using the terminology naturopathy is not a limited patent system of proscrip- of the period purchase retrovir 100mg line. Drugless healing was used to differenti- tive natural therapeutics – for example prescribing sitz ate a general category of practice generic retrovir 100 mg with mastercard, not only in relation baths and wet sheet packs for all patients 100 mg retrovir fast delivery. Instead purchase retrovir 100 mg free shipping, to non-allopathic systems of healing at the time but naturopathy individualizes treatment in an eclectic also to differentiate the category from homeopathic and progressively minded fashion. The approach of practice and from the botanical practices of the time universal prescription was an early trend derived from such as eclecticism. For example, Dr Staden sion of the therapeutic worldview of the naturopath describes two cases of cancer treated with topical beyond universally applied systems for all disease. Chapter 3 • History of Naturopathic Physical Medicine 63 Lust argued that naturopathy is a larger inclusive ﬁeld The renaming of the title and Lust’s choice of this that expands beyond its nature cure foundations. So text as a textbook of practice indicates the early orien- what was naturopathic practice like during the ﬁrst tation of the profession’s leadership. Other modalities such as sunlight, the legislature they declared that the practice of natu- breathing therapy and electricity play a supplemental ropathic therapeutics consists of: role, as do botanical teas, steam baths and injections. There is scant reference to naturopaths prescribing • Dietetics homeopathic or allopathic medications. Prior • Hydrotherapy scholarship was also used to demonstrate historical • Physical Culture antecedents. For example, in 1902 Lust republished • Dynamic Breathing an article from the ﬁrst half of the 19th century, ‘The Sweating Cure for Hydrophobia’, in which • Massage Richard Metcalfe relates ﬁve successful case histories • Swedish Movements of rabies transmitted from animal to human that were • Structural Adjustments treated with Turkish steam cabinet baths (Metcalfe • Sun 1902). These include • Kneipp Cure a 10-month-old paralyzed boy originally diagnosed by allopathic doctors as a case of spinal meningitis, a • Just Cure case of acute peritonitis with a swollen abdomen, • Fasting cancer of the jaw, and pneumonia with ‘brain fever’ • And other simple natural agencies as Rest, (presumably meningitis). The Aside from the non-poisonous herbal remedies uti- cancer case also utilized electric light baths as part of lized in the Kneipp cure, the therapeutic means listed the therapy. The naturopathic treatment procedures in this period for various conditions such as gonorrhea, Eclectic naturopathy syphilis, diphtheria, infantile paralysis, meningitis While the early naturopathic profession included inter- and other infectious diseases detail what are primarily nal medication such as botanical medicine and homeo- physical methods of treatment allied with diet. In a pathic medicine in its larger conception of naturopathic 1909 article on spinal meningitis, Dr Lust refers to the practice, it would not be until the demise of the physi- naturopathic approach to treatment as ‘physical- cian level botanical (e. Originally entitled Physical Therapeutic viduals, professional groups and ideas would be Methods: A Handbook of Drugless Medical Practice when absorbed into the naturopathic profession. The profes- published in 1910, Lust republished the book in 1916 sional literature of the 1930s and 1940s documents the as A Treatise on Naturopathic Treatment: Based on the naturopathic professional absorption of those wither- Principles and Therapeutic Applications of the Physical ing professions with articles that focus more and more Modes and Methods of Treatment(Non-Medicinal Therapy). Naturopathy is a distinct school of healing, employing the beneﬁcent agency of Nature’s forces, or water, air, The ‘Physio-Therapists’ and naturopathy sunlight, earthpower, electricity, magnetism, exercise, In an interesting article ‘The Two Brands of Naturopa- rest, proper diet, various kinds of mechanical thy’ by E. The result therapist’ group that incorporated various physical of such ministrations is wholly beneﬁcent. This categorization is somewhat prophylactic power of Nature’s ﬁner forces, mechanical analogous to the chiropractic division between and occult, removes foreign matter from the system, ‘straights’ and ‘mixers’. The former group advocates restores nerve and blood vitality, invigorates organs limiting practice to adjustment of the spine and the and tissues, and regenerates the entire organism. The naturopathic division was between This eclectic view was also translated into a perspec- one group that would limit themselves to fundamen- tive that all individual natural healing arts – including tal nature cure techniques and the other that would osteopathy and chiropractic and eventually eclectic implement appliances such as sine wave, diathermy, botanical practices and homeopathy – were single galvanic, etc. It was men- By the 1930s and 1940s the ideas of the naturopathic tioned earlier that in 1924 the California State Supreme physiotherapist or mixers of the naturopathic profes- Court determined that chiropractic was a branch of sion were far more prominent. However, it should Naturopathy, osteopathy and massage be pointed out that these methods were utilized in a fashion consistent with the naturopathic and nature The early naturopathic professional view was also cure theories that predominated in the profession at historical and cross-cultural. Claims Medical Doctors have even taken the name of our by individuals to have discovered one of the ﬁelds of science, ‘Naturopathy’, and translated it into its Greek drugless therapy, rather than to be elaborating upon synonym ‘Physiotherapy’. Then they have so arranged an ancient and evolving art, were regularly chal- it with the powers that be that a ‘Naturopath’ cannot lenged. For example, in the 1913 article ‘Osteopathy any longer practice his art – in this Commonwealth Not a New Science of Healing’ the author Dr Thirion anyhow [referring to New York] he must be a takes issue with the claim of osteopathy’s ‘discovery ‘Physiotherapist’. Dr Thirion relates the use of early physiotherapy at some institute stipulated by the massage techniques by Herodicus, Hippocrates, medical doctors as the original and sole source of such Asclepiades, Celsus and Galen, as well as the contem- a science. Fight for your rights, for you will never porary practices of the day of Amma-Amma of the get them in any other way. Japanese, Toogi-Toogie in the Tonga Islands, Pidjetten It should be pointed out here that in 1945 the Aus- in Malaysia, and the Turkish bath massage practices. Finally, he lists extensive references prior to Dr Still such as Therapeutic Manip- Naturopathic physical medicine emerges ulation by De Betou (1840), Kinesipathy by Dr Georgii We can make several conclusions regarding naturo- (1850), Cases of Scrofula, Habitual Constipation, etc. Interesting is Thirion’s ref- physical medicine played a tremendously large role erence to Henrik Kellgren, a pupil of Ling, who had in practice. The second is that physical methods were great success in treating infectious diseases such as being employed not only for musculoskeletal ailments Chapter 3 • History of Naturopathic Physical Medicine 65 (the restricted ﬁeld commonly encountered with The body packs to which Dr Lust refers are the cold modern-day physical therapy) but also for the reha- wet packs of Kneipp, a very commonly prescribed bilitation of chronic disease and for acute infectious method at the time. These modalities of physical medicine to the application of wet packs considerably in Natural included hydrotherapy, electrotherapy, exercise, Therapeutics. The cold towel application in constitu- reﬂexology, massage, spinal adjustment, cupping tional hydrotherapy and the modern-day warming (vacuum therapy), and various other derivatives and sock are examples of variations of the wet pack. A second dry layer most commonly of physical rehabilitation, the early naturopathic physi- wool is then wrapped over the sheeting, the second cal medicine approach did not limit itself to these layer acting as an insulator. Case reports of meningitis, diph- Naturopathic management of theria, scarlet fever, inﬂuenza, pneumonia, polio, poliomyelitis measles and all manner of infectious diseases can be found in the naturopathic literature. How conﬁdent were the naturopaths in managing acute infectious diseases through the methods of the period which were primarily ‘physical therapy tech- The great ﬂu pandemic and other niques’? In the 1934 article ‘Infantile Paralysis infectious diseases Controlled by Naturopathic Physicians’, Dr Carl For example, during the 1918–1919 inﬂuenza epi- Frischkorn reports that his state association (Virginia) demic, 290 ‘drugless doctors’ using naturopathic would draft a bill to present in the legislature to ‘make methods reported managing 14 841 cases with 18 it unlawful for a medical doctor to take a case of deaths. This mortality rate of about 12 per 10 000 is Infantile Paralysis [polio] unless it is found impossible compared to the reported mortality rate for medical to get a Naturopathic physician’. The If we examine the methods outlined in the book Polio- overall mortality rate for the epidemic is generally myelitis by the osteopath Millard (1918) we will dis- conceded to be approximately 2. Claunch cover at least two important insights, aside from the reported working at one of the largest naturopathic description of a successful method of managing both sanitariums in Chicago where 300 cases were man- acute and chronic cases of polio and related viral dis- aged without a single mortality. The ﬁrst insight we will discover is that while Hospital, two blocks away, lost 54 of every 300 cases individual cults of the time were supposedly claiming (Clements 1926). The second of Dr Claunch we can be relatively conﬁdent that he insight we will discover is that this therapeutic eclecti- is describing the Lindlahr Sanitarium and Lindlahr cism is essentially a naturopathic approach by any stan- has described his methods of handling acute or infec- dard, quite similar to the naturopathic treatment of tious diseases in Natural Therapeutic: Practice. It is highly likely that the methods Millard methods of Lindlahr are quite similar to the treat- describes were similar to the Virginia naturopaths who ments outlined by Dr Lust (1930) in his book The attempted to legislate primary access to polio cases in Naturopathic Treatment of Disease: 1934. Indeed, the outlined methods are remarkably similar to the methods described by the naturopath Dr 1. For rable to the management of all acute infections advo- variety take grapefruit, or diluted lemon juice may cated by Lindlahr (1918) in ‘Acute Disease and Its be used. There 66 Naturopathic Physical Medicine are a number of contributing doctors, 39 in all, with 3. Concussion at nerve centers details of 56 case histories as well as descriptions of 4. Collins in the early 1920s and passed, was uniformly helpful and signiﬁcant prog- a good deal more will be discussed on that topic later ress could always be made.
Disease was a mal function in the hum an machine effective 100 mg retrovir, caused either by an internal disorder 100mg retrovir sale, or by the activity o f an external agent purchase 100 mg retrovir with amex. T he most effective way to treat disease was first to accurately classify it retrovir 100mg overnight delivery, then to apply to it a set of techniques designed to produce a like cure in like patients. Since what was to be done was deliver a service, increasingly thought of as a commodity, a delivery system was created. And it was also this period that witnessed the rise of technical medicine, and the attrition o f the arts of medicine. Much of this book is de voted to the description and analysis o f m odern medicine. Chapter 3, for example, contains a fairly detailed treatm ent of the delivery system. T he purpose o f this section is to isolate those characteristics o f m odern medicine that underpin the cur rent medical paradigm. O ur view of health is about the same as it was in the early part of this century. Disease is still presum ed to be the result 210 The Transformations of Medicine o f faulty machinery. And because all machines are roughly the same, treatm ents are finely tuned to fit discrete diag noses. Specialization is inexorable, and the delivery system has become so highly elaborated that the average patient is often greatly confused. But most significant has been the further conceptualization of the patient as a machine of great complexity. In the past physicians may have thought of their patients as machines, but nevertheless had to treat them as whole machines. Today, with the exception o f a few hardy rural practitioners and family physicians, medicine has com partmentalized the body into finer and finer machine parts. It is one thing to treat a patient as a machine, ignoring a rich store of infor mation that is related to health and functioning, and yet another to further subdivide the machine into its constituent parts. In the forpier medicine, at least the possibility existed for holistic treatm ent. T he technologies o f today’s medicine reflect its impervi ousness to factors conducive to health. Drugs flow nearly un im peded from doctor to patient, and are often prescribed for conditions like viral disorders, for which there is no chemical cure. T he delivery system has become large, un wieldy, and complex—an industry in search of newer and refined products. Some of the m ore elaborate technologies illustrate the preoccupation o f the system with technical en gineering. T he coronary care unit and the kidney dialysis machine link the patient, the machine, into a fixed feedback loop with another machine. M odern medicine is only one approach to health—a wholly disease-oriented approach. Its paradigm of healing assumes that highly refined techniques and profound inter ventions into the body can produce health by eliminating the The Eras of Medicine 211 symptoms o f disease. This has led to the neglect of popula tion medicine because there is no paying consumer; the neglect of social and environm ental conditions, because physicians are only trained to intervene at the individual level; the neglect of a blizzard of phenom ena about the hum an being, because it does not fit the paradigm ; and finally neglect of the role o f the individual in achieving health, because if health is a commodity it must be delivered to a manipulable public. This is because to the physician the hum an being is simply a machine with interchangeable parts. A given disease can be treated identically in Peoria or in Phoenix; it is the disease that is being treated, not the per son. Aside from its convenience to the harried doctor, immobi lization is the same as turning o ff the engine in a car and leaving it in a stall at the mechanic’s shop. While we do not know enough about what produces health we know some things—com- monsense things. For example, we know that a nutritious diet, recreation, fresh air, and sunlight are related to health. But because the hospital is a factory for the repair o f disease, none o f these things are readily available. Hospital food is not only tasteless, it is not nutritious— nothing is fresh, everything is frozen, white bread and butter are served, and so on. T here could be gyms and exercise rooms, but a person doing yoga or any other bodily exercise faces deri sion, even prohibition. And there is little opportunity to be 212 The Transform ations of Medicine outdoors; hospitals are hermetically sealed chambers. The only way a patient can get outdoors (if there are any grounds) is to grope his or her way to the front door and then face the possibility o f alarm from the m atrons at the admissions desk. Today’s medicine has succeeded where the medicines of the past have failed: it has succeeded in equating medical care with health. T hrough biological adaptation m an has survived; and through adaptation, not medical care, man has achieved im proved health. T he environm ental insults of the industrial age—contam inated water and lack o f sanita tion, the unavailability of basic nutrients, uncontrolled epidemics and an inadequate understanding of infectious transmission— have been mostly m anaged. These include air quality, chemical treat ments o f foodstuffs and other products, overindulgence in food and drugs, stress, the pace of life, congestion, noise, and the lack of recreation and exercise. T he contribution of medical care was m inor in the adaptation o f man to the industrial threats to health; and similarly, it has only a m inor role to play in the adaptations that now face us. T he reason lies in the paradigm o f health that medicine has con A New Paradigm 213 ceived—the “science of the organized individual,” to use A. Crombie elaborates: The biology of the individual is more like engineering than physics, in that each type of living organism is a solution to a specific set of engineering problems—problems of intake and conversion of fuel, locomotion, communication, replication and so on which it has to solve to survive. This subject matter has imposed on physiology its characteristic program: to find out how an organism works by taking it to pieces and trying to put it together again from knowledge of the parts. As a result it has sought to engineer hum an health through the m anipulation o f hum an parts. John Powles has examined this question in some detail in his paper “O n the Limitations of M odern Medicine”: The engineering approach to the improvement of health has been dominant over an alternative approach which would em phasize the importance of way of life factors in disease—an approach which could be described as “ecological. Curative medicine has not been very successful in reducing the impact of diseases of maladaptation. Despite the evidence to the contrary, it is widely believed by both patients and their doctors that industrial populations owe their high health standards to “scientific medicine,” that such medi cal technology as currently exists is largely effective in coping with the tasks it faces and that it offers great promise for the future. There was only one question Ivan Illyich wanted answered: was his condition dangerous or not? One had only to weigh possibilities: floating kidneys, chronic catarrh, or an ailment of the caecum. There was no question of the life of Ivan Illyich—nothing but a contest between floating kidneys and the caecum. In the presence of Ivan Illyich the doctor gave a brilliant solution to the problem in favour of the caecum, with the reservation that the analysis of his water might supply new information necessitating a reconsideration of the case. But it is in the relationship be tween hum an beings and their environm ent that the key to health lies.
Cortisol is produced in bursts throughout the night discount 100mg retrovir with amex, reaching a daily maximum at c buy generic retrovir 100 mg online. For example generic retrovir 100mg visa, Allen ea (1991) failed to find a significant difference in the lateralisation of tactile-evoked potentials when a stimulus was evoked to the index fingers of patients with schizophrenia and age- and sex- matched controls buy retrovir 100 mg with visa. P3 (P300) abnormalities (showing differences from controls) have been reported in schizophrenia, behavioural problems,(Iacono ea, 2002) memory disorders like Alzheimer’s disease, attentional disorders, and, as a trait marker, in the offspring of alcoholics,(Polich ea, 1994) and in affective disorders (Hall ea, 2009); abnormalities may involve amplitude, latency or the positioning of the peak over the head. The subject looks at a smoothly moving target, such as a pendulum or a moving spot. Excess jerkiness - a disrupted, jagged pattern - is found in most, but not all, schizophrenic subjects, in about 45% of their parents and siblings - who may not have overt illness, and in around 8% of the general population. According to Kathmann ea,(2003) over 80% of have abnormal smooth pursuit tracking with about one in three of their relatives having similar problems. Saccades These are fast, ballistic eye movements that bring the fovea centralis and the target together, e. The eye may jump ahead of the target (anticipatory saccades) or, because of reduced gain (speed of eye v speed of target), the eye falls behind the target and uses a catch-up saccade to bring it back to the target. Antisaccades A subject is asked to fixate a central dot that steps at random to left or right. When the target steps into the periphery the subject is asked to look away from the target to the opposite side. It requires inhibition of the temptation to look to the side where one remembers the target to be: when one must inhibit the reflex to look toward a light (prosaccade) and instead consciously look in the opposite direction (antisaccade), schizophrenic subjects have great difficulty not turning their eyes to the light. Xenon is an inert gas that does not affect physiological or biochemical processes. Follow up of Swedish men who received radiation treatment for cutaneous haemangioma aged less than eighteen months found evidence of cognitive damage. Three years later a prototype whole-body scanner was installed at Northwick Park Hospital, Middlesex. One-quarter of schizophrenic patients show early signs which unrelated to inpatient care or medication; in two-thirds of these there is non-specific enlargement of the third and lateral ventricles; more localised lesions, such as aqueductal stenosis or septal cavities are also reported. A link between ventricular enlargement in more advanced schizophrenia and perinatal intraventricular haemorrhage has been suggested. Diffusion weighted imaging detects random movement of tissue water and quantifies such movement using an average apparent diffusion coefficient which is then mapped onto the brain. One in twenty normal adults will have evidence of small parenchymal haemorrhages, although some haemosiderin deposits are removed over time. If an isotope such as 15O has more protons than neutrons it will emit positrons to achieve stability. Therefore, an increased positron emission rate indicates an increased metabolic rate and increased glucose utilisation. The very short half-life of the tracer allows collection of many images, separated by about 10 minute intervals, within a single session. Mazziotta ea,(1987) in a controlled study of Huntington’s disease, reported a marked decrease in glucose metabolism in the caudate nuclei of both symptomatic and asymptomatic at-risk subjects. Multi-infarct dementia is characterised by patchy reductions in cerebral blood flow and metabolism,(Kumar, 1993) and fairly distinctive patterns are found in Pick’s disease and Parkinson’s disease with dementia. Major depression in the elderly is associated with reductions in whole brain glucose metabolic rates comparable in magnitude to those found in Alzheimer’s disease. The latter fact makes it difficult to do multiple pictures at one sitting because one has to subtract residual radioactivity from any previous scan; also, high radiation exposure limits one to 2-3 scans/person/year. However, the region of interest methodology has given way to various voxel-based techniques (e. Up to 80% of Alzheimer patients show reduced blood flow (and glucose metabolism) in the cortex of posterior temperoparietal regions; there is relative sparing of primary sensory areas and subcortical regions. During tasks that activate the frontal lobes, patients with schizophrenia, unlike controls, fail to increase blood flow to the frontal cortex. It is useful for delineating problems in the posterior fossa, the cranio-cervical junction, and the neural canal. T1 relaxation time rose immediately after the fit, reaching a maximum 4-6 hours later, T1 values then returning to baseline. Interestingly, in a very small study of patients with cerebral trauma,(Buckley ea, 1993) those with an illness resembling schizophrenia, but not those with a schizoaffective-like disorder, had left temporal lobe abnormalities. In the Rangel-Guerra ea (1983) study of bipolar affective disorder patients, the latter had longer brain proton T1 relaxation times that normalised after lithium treatment, whereas lithium had no effect on this perameter in normal control subjects. Knauth ea (1997) demonstrated multiple brain lesions in sport divers in association with a large patent 385 foramen ovale that might be explained by paradoxical arterial gas embolism. It provides information on the directional orientation of white matter tracts and informs us of their structural integrity. By controlling the position of light source and detector and by extremely fast recording (in milliseconds) one can get an idea of signal source and temporal change. Because of poor penetration of light, activation of deep brain structures are not detected. It uses the brain’s natural haemodynamic response to neural activity as an endogenous tracer. The subject must tolerate scanner noise and close confinement 387 Thanks to the pioneering work of Charles Dumoulin during the 1980s. Oxygenated haemoglobin is slightly diamagnetic and causes weak disturbances in the local magnetic field. On the other hand, deoxyhaemoglobin is paramagmetic, aligns with an applied magnetic field, and increases the strength of the local magnetic field. Natural emissions from atomic nuclei activated by magnetic fields are used to measure concentrations of molecules within the body. There are no ‘pictures’, just quantitative measurements, a display of the spectrum of certain chemicals. This very small field can be measured at the scalp (a magnetically shielded room and very low temperatures for the loop are required). The ability to detect deep brain discharges using this method may obviate the need for indwelling electrodes. In one study,(Reite ea, 1997) controls demonstrated asymmetry in an auditory-evoked field component (100-msec. Resolution and spatial accuracy declines as the further one moves from the cortex. Application of a radiofrequency pulse tuned to the frequency of the specific element yields a spectrum that is caused by the different compounds containing the specific element. Prenatal ultrasonography at 19-23 weeks gestation found a non-significant trend towards increased lateral ventricular width in offspring of mothers with psychosis. Cognitive subtraction paradigm An image of neural activity (be it blood flow or electrical activity) is taken before (control state) and during (task state) a task and the difference (subtraction) shows what brain parts are used for that task. In practice averages across intra- and interindividual repeated task performance are used in order to control for ‘noise’. Sleep disorders Sleep disorders in children, although distressing at the time, are mostly developmental: they grow out of them. Clues to the need for further investigation are very frequent occurrence, onset in or persistence into late childhood, appearance after a traumatic event, and other evidence of psychological disturbance.
This is a gross oversimplification proven retrovir 100 mg, but in general discount 100 mg retrovir visa, x Pneumonia- pneumococci buy generic retrovir 100 mg line, Haemophilus buy 100 mg retrovir mastercard, Pseudomonas, Staphylococcus, Klebsiella x Aspiration pneumonia – oral anaerobes x Urinary tract infection – Coliforms Pyrexia 35 Handbook of Critical Care Medicine x Cellulitis of a limb – Staphylococcus, Streptococci, Gas forming organisms x Meningitis – Meningococcus, Pneumococcus, Listeria, x Intra-abdominal infection – coliforms, intestinal anaerobes 7. Thromboembolism, pancreatitis, drug induced fever, neuroleptic malignant syndrome, Cerebrovascular events involving the pons or hypothalamus. Relevant clinical examination A relevant detailed clinical examination is of utmost importance. Next, starting from the head, do a detailed screen of x Haematomas on the scalp (infected), abscesses x Neck rigidity and Kernig’s sign x Sinuses – tenderness. Low blood pressure with a wide pulse pressure may herald the development of septic shock. Investigations The most commonly performed investigation is a white blood cell count. A high total count with neutrophil leukocytosis suggests bacterial infection; examination of the blood picture may demonstrate a ‘left shift’, and toxic granulation of the neutrophils. Remember that a low white cell count 9 (below 4 X 10 /L) could also indicate infection. If fever occurs, blood culture must be taken before antibiotics are started, or, if the patient is already on antibiotics, before changing the antibiotic regimen. If present, any fluid from drains should be sent for culture, together with wound swabs and pus from discharging wounds or abscesses. Routine throat swabs, nasal swabs, skin swabs (groin, axilla) are of no particular use. Common mistakes x Starting antibiotics before taking appropriate cultures x ‘The patient is on antibiotics; therefore I did not take a culture’. If the patient develops a new infection while on a particular antibiotic, it is likely that the current antibiotic therapy is ineffective. Pyrexia 37 Handbook of Critical Care Medicine Taking cultures from intravenous lines When line sepsis is suspected, the catheter should be removed, and the tip of the catheter sent for culture, together with a peripheral blood culture drawn at the same time. If only the catheter tip culture grows an organism, it is likely to be simply a colonising organism. If both cultures show the same organism, it is likely that catheter was the source of infection. Significance of blood culture results Commonly identified micro-organisms causing nosocomial infection include Gram-negative bacilli such as Enterobacteriaceae, Klebsiella, Pseudomonas, Acinetobacter and Serratia spp, Gram-positive bacteria such as coagulase- negative Staphylococci and S. Staphylococcus epidermidis cultures may not be of clinical significance, unless present in more than one bottle, and rapidly growing in culture. Whether to take a Candida culture seriously depends largely on the clinical state and risk factors of the patient. For example, if a long stay seriously ill patient, who has been on multiple antibiotics, produces a blood culture positive for Candida, the clinician may decide to start on antifungal agents. Radiological investigations Chest x-ray is the most useful radiological investigation. The appearance of new areas of consolidation could indicate the development of pneumonia. In a ventilated patient, it could mean the patient is getting ventilator associated pneumonia. Ultrasound scanning of the abdomen is useful to detect intraabdominal abscesses, liver abscesses, cholecystitis, pyelonephritis, and pelvic infections. Transthoracic and transoesophageal echocardiography are useful in diagnosing endocarditis, when suspected. Pyrexia 38 Handbook of Critical Care Medicine Nuclear imaging techniques, such as Gallium scanning, are theoretically useful, but often of little practical value in critically ill patients. Antibiotics should be started early in critically ill patients, and broad spectrum antibiotics should be used. The choice of the antibiotic depends on the suspected site of infection, and is based on the common organisms which cause such infection. Where the source of infection is not identified, broad spectrum aerobic and anaerobic antibiotic cover is used. Antibiotics should be chosen carefully, given for at least 3 days before they are deemed not to be effective, by which time culture results should be available. Clinicians often change antibiotics too early and too often, giving inadequate time for them to work. Piling antibiotics with the same range of cover on top of each other should be avoided. Patients admitted with other critical illnesses often develop infection while in hospital; this is known as nosocomial or hospital acquired infection. In some patients, infections respond to simple antibiotics, and resolution is rapid and complete. It is often difficult to predict how a patient with infection will progress; however, there are certain risk factors which predict that the course of infection will result in complications. Infections are usually more likely to run a complicated course if the patient is of advanced age, if comorbid conditions such as diabetes, chronic liver disease, chronic renal disease, chronic obstructive airways disease, heart failure or malignancy are present, or if the patient is immunocompromised. Infection which occurs more than 48 hours after admission to hospital is defined as nosocomial infection. Intravenous lines are an important source of bloodstream infections, and urinary catheterization increases the risk of urinary tract sepsis. Sepsis, severe sepsis with multiorgan failure, and septic shock are increasingly severe complications of infection, with correspondingly higher mortality. Early recognition of infection, and early prediction of sepsis and its complications is crucial, though not always easy. Early treatment, with antibiotics and source control (removal of the source of infection) improves mortality and morbidity. There is no universally reliable tool to diagnose sepsis early or to predict its progression. A high degree of alertness to changing parameters, as well as anticipation of the development of sepsis with initiation of preventive measures is therefore important. For example, the development of tachypnoea or a drop in blood pressure may herald the development of severe sepsis. Newer markers such as procalcitonin levels have been suggested to be useful, but evidence is still forthcoming. Worsening clinical parameters will alert the clinician to the development of severe sepsis and multiorgan failure. The patient presents with fever, cough with expectoration, sometimes the classical “rusty sputum”, pleuritic chest pain, and on examination has either evidence of lobar consolidation (crackles, bronchial breathing, whispering pectoriloquy). Depending on the severity and the infecting organism, as well as the patient’s immune status, signs maybe bilateral. Streptococcus pneumoniae, Legionella, Haemophilus influenzae, Klebsiella, gram negative bacteria and Staphylococci are the common ‘typical’ infections; in up to 40 % of patients, the infecting organism is not identified. Patients with neutropenia are more susceptible to infections with gram negative organisms including Pseudomonas. The following investigations are required: x Chest radiograph: multilobar involvement, and the presence of a pleural effusion indicates worse prognosis. Apical involvement is seen in Klebsiella pneumonia, and also in tuberculosis, although the clinical course is different in the two conditions; tuberculosis having a more indolent course.
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