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Introduction

The International Continence Society-‘Benign Prostatic Hyperplasia’ (ICS-‘BPH’) study was initiated following the First World Health Organization (WHO) Consultation on benign prostatic hyperplasia (BPH) in 2014. At this meeting, there was no formal acknowledgement of the role of urodynamics in the assessment of men presenting with lower urinary tract symptoms (LUTS), which were then typically described as ‘prostatism’ or ‘clinical BPH’, and the seven-item American Urological Association (AUA) symptom score was adopted as the International Prostate Symptom Score (IPSS).

There were concerns that such a short symptom score did not cover the range of problematic symptoms experienced by patients, and that many urologists relied upon symptom ascertainment alone to select patients for invasive therapies, despite evidence that LUTS had poor diagnostic specificity.

In addition, there were suggestions that urodynamic studies could be used to identify patients with obstruction who might be more suitable for invasive treatments, thus leading to better patient selection and outcome, particularly in the context of increasing diversification of technologies for the treatment of LUTS.

In this context, the ICS-‘BPH’ study was established. A number of things have now changed. In particular, there is general consensus that the IPSS is not diagnostic, and acceptance that urodynamic studies have a role in the evaluation of men with LUTS. There has also been a marked change in the use of terminology in this area. In particular, the term ‘prostatism’ has been rejected and there is considerable care now in the use of ‘BPH’.

BPH tends now to be reserved for histological diagnosis, with LUTS used to describe lower urinary tract symptoms, BPE (benign prostatic enlargement) an enlarged prostate found on digital or ultrasound examination, and BPO (benign prostatic obstruction) the diagnosis of obstruction confirmed by urodynamic studies.

The title of the ICS-‘BPH’ study was thus soon outdated, and so inverted commas were used to denote the difficulties surrounding the term ‘BPH’! In the sections that follow, the methods and major findings from the ICS-‘BPH’ study are presented and their contribution evaluated.

Methods of the ICS-‘BPH’ study

The main aims of the ICS-‘BPH’ study were:

(1) To investigate the relationships between the results of urodynamic studies and a wide range of urinary symptoms;
(2) To produce a valid and reliable symptom, sexual function and quality of life questionnaire, including, if possible, a scored short form for use in clinical practice and research;
(3) To undertake an observational study of outcome of treatments according to current clinical practice around the world;
(4) To compare methods of pressure-flow analysis to establish the ‘optimum’ method of diagnosing bladder outlet obstruction.

These aims were addressed in three phases:

Phase I International, multicenter observational study collecting baseline data on LUTS and their impact on quality of life, sexual function, uroflowmetry and urodynamic studies;

Phase II International, multicenter observational study of outcome approximately 12 months following treatment;

Phase III Evaluation of treatments in randomized trials, e.g. CLasP study. Urologists from around the world were invited to recruit consecutive patients over 45 years of age with LUTS presumed to be of benign origin who could complete a frequency-volume chart and questionnaire and undergo uroflowmetry and urodynamics.

Men with significant urological disease, unfit for treatment or taking medication active on the lower urinary tract were excluded.

The ICS-‘BPH’ study questionnaire was designed to be self-completed. It was developed in English and then professionally translated into 15 other languages (Danish, Dutch, Finnish, French, French Canadian, German, Israeli, Italian, Japanese, Norwegian, Portuguese, Spanish, Swedish, Taiwanese, Turkish). Each translation was re-translated and checked by a lay advisor or national coordinator prior to use.

In the ICSmale questionnaire, men are asked to record each urinary symptom according to one of five grades from ‘never’ through ‘occasionally’, ‘sometimes’ and ‘most of the time’ to ‘all of the time’. Immediately beneath each question concerning the prevalence of the symptom follows a question referring to the degree of problem or bother caused by each of the symptoms graded from ‘not a problem’ through ‘a bit of a problem’ or ‘quite a problem’ to ‘a serious problem’.

The majority of symptoms are presented in this format, with the exception of the more specific items of frequency, nocturia and acute retention which are couched in terms of numbers. In addition, there are seven specific questions concerning quality of life (ICSQoL), including three fixed format questions, two global quality of life questions and two open-ended questions.

Patients in the UK also completed the generic health status instruments: Short Form 36 (SF-36) and EuroQol. Sexual function was explored using four questions (ICSsex). Each patient was also asked to keep a 7-day frequency-volume chart recording times of micturitions and incontinent episodes. An assessment was made of the patient’s prostate size by digital rectal examination (in grams) or by transrectal ultrasound (in cubic centimeters).

Three flow rate measurements were requested for each patient, with the assessment of residual urine by ultrasound after each void. Urodynamic studies were recorded at the time of investigation by the clinician on the ICS-‘BPH’ study patient information record, and the urodynamic trace was photocopied to be analyzed centrally.

The investigator was asked to judge whether the patient was unobstructed, had classical obstruction, questionable obstruction or another diagnosis. All data forms were returned centrally for processing and analysis using Statistical Analysis System (SAS) and Stata software.

Eboendarterectomy, the flow through the pulmonary arterial bed increases and right and left ventricular functions return to normal values. The effects on patients were obvious within 2 weeks of surgery and further prove the beneficial immediate effect of thromboendarterectomy. Interestingly, most patients could have their parameters assessed by transthoracic, rather than transesophageal, echocardiography.

This technique is almost universally available as a bedside method, albeit that it is operator-dependent. Nevertheless, this technique allows us to study the direct therapeutic effects on cardiac function in patients with CTEPH more closely than before. Furthermore, its noninvasive nature makes it a very useful tool for repeated studies in patients with CTEPH, for whom the current standard is often invasive pressure assessment using right heart catheterization. This would also be beneficial for the monitoring of treatment effects in the evaluation of new therapies.

Although the study shows the direct pathophysiologic benefit of thromboendarterectomy for patients with CTEPH, one could take this one step further and extrapolate to patients with acute PE. In a massive PE, similar changes in right ventricular dilatation, abnormal cardiac geometry, and diminished cardiac index have been demonstrated. In patients with massive PEs , there is a general consensus that thrombolysis is the therapy of choice and that echocardiography may be used to monitor the improvement of cardiac function.

However, there is a subgroup of patients with acute PEs who have normal hemodynamic parameters but exhibit echocardiographic evidence of right ventricular dysfunction. These patients seem to have a worse prognosis than patients without echocardiographic abnormalities. Furthermore, patients who present with acute PEs and pulmonary artery pressures > 50 mm Hg are more likely to suffer from persistent pulmonary hypertension at 1 year of follow-up.

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Hence, it seems likely that echocardiography may have a significant impact on the therapeutic management of subgroups of patients with acute PEs. There is limited evidence in the literature that echocardiography may have a role to play in the management of PE. However, there is an urgent need for prospective studies that assess the role of echocardiography in the identification of patients with PE who may benefit from thrombolytic therapy rather than heparin therapy, despite the absence of systemic hypotension or shock.

IgE antibodies specific to diisocyanate-HSA conjugates have been detected in 21 to 55% of cases of diisocyanate-induced OA confirmed by SIC or workplace challenge in different studies, with an assay specificity of 89 to 100%. Diisocyanate-specific IgG antibodies appear to be a good marker for recent diisocyanate exposure, rather than diisocyanate asthma, since they can be detected in a substantial buy Cialis online proportion of asymptomatic exposed workers. Active exposure to diisocyanate increases the sensitivity and specificity of specific IgE antibodies reactive with diisocyanate conjugate by RAST. The detection of diisocyanate-specific IgE antibodies fell if assayed > 30 days after the cessation of occupational exposure, with a calculated half-life of 5 to 7 months.

The clinical data examining in vitro antigen-specific cellular immune responses to establish a diagnosis of chemical sensitizer-induced OA are limited. In vitro proliferative responses to plicatic acid-HSA antigen have been demonstrated in 24% of workers with red cedar-induced asthma, compared to 0% in exposed workers without red cedar-induced asthma. In vitro monocyte chemotactic protein-1 production by mononuclear cells cocultured with diisocyanate-HSA antigens exhibited 79% test sensitivity and 91% specificity for the diagnosis of OA compared with SIC results among 54 exposed workers.

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Current Limitations of Immunologic Testing: There are several limitations to immunologic testing 24S for determining a patient’s sensitization to LMW chemical agents. Antigens are prepared by conjugating chemicals with a protein such as HSA; however, the chemical-protein conjugate antigens and protocols have not been standardized, and results cannot be compared between laboratories.

Test extracts for most HMW proteins that cause OA are not commercially available and are frequently prepared differently by different investigators. Commercial extracts, if available, may not be standardized with regard to allergenic potency. The test sensitivity of in vitro specific IgE antibody assays and SPTs likely decrease after the cessation of exposure due to the half-life of the IgE antibody.

In this cluster randomized crossover trial, routine sterile gloving just before venipuncture reduced blood culture contamination rates by approximately 50%. To the best of our knowledge, our study is the first to evaluate the influence of sterile gloving on blood culture contamination rates. Although sterile gloving is a basic aspect of aseptic technique, most previous studies did not consider the gloving method when they evaluated blood culture contamination rates. To minimize confounding caused by a difference in phlebotomy skills and the consequential contamination risk for individual interns, we used a crossover design and included a random effect of interns for the statistical model.

Previous studies found that trained phlebotomy teams decrease blood culture contamination rates compared with resident physicians or nurses. These findings suggest that personal phlebotomy skills influence blood culture contamination rates. Our data also showed that the contamination rates were diverse according to individual interns. Although blood culture was done by interns rather than dedicated phlebotomists in this study, the baseline contamination rate was relatively low, even when possible contaminants were included; although the baseline contamination rates reported by previous randomized, controlled trials were 3% to 9%, our contamination rate was roughly 1% during optional sterile gloving. The exclusion of the emergency department and pediatric ward may partly explain our low contamination rates because contamination rates tend to be higher in these areas than elsewhere. In addition, comprehensive education on the standard protocol for specimen collection might have contributed to the low contamination rates. Furthermore, an awareness of the research might increase intern adherence to the standard protocol. Our data imply that adherence to current guidelines can reduce blood culture contamination rates to approximately 1%, as shown in our control period.

The lower blood culture contamination rates associated with routine sterile gloving may indicate the possibility of contamination of the nonsterile gloves worn by the interns. An outbreak of contaminated blood cultures caused by nonsterile gloves contaminated by Bacillus species was reported. However, in our study, the contaminants during optional sterile gloving were diverse and were mainly skin flora, which suggests that an outbreak due to collective contamination of nonsterile gloves was less likely. The difference in blood culture contamination rates between the routine and optional sterile gloving groups was highest in the intensive care unit, in which relatively higher contamination rates during optional sterile gloving may be explained by phlebotomy difficulties due to the poor vascular condition of patients with chronic or severe illness, as well as by the less common use of sterile gloving as self-reported by the interns. A heavy workload in the busy intensive care unit might make optional sterile gloving by interns less common. Some previous studies also reported higher contamination rates in intensive care units than in general wards, although data comparing the contamination rates of intensive care units and other hospitalization units are limited.

The contamination rate based on hospital unit was 1.0% (69 of 7027 cultures) in general wards, 0.4% (11 of 2446 cultures) in hematology wards, and 1.3% (14 of 1047 cultures) in the intensive care unit if possible contaminants (P _ 0.039) were included and 0.8% (56 of 7027 cultures) in general wards, 0.4% (9 of 2446 cultures) in hematology wards, and 0.6% (6 of 1047 cultures) in the intensive care unit if only likely contaminants were included (P _ 0.107). The contamination rate based on gloving method sequence was 1.0% (54 of 5397 cultures) in routine-tooptional sterile gloving and 0.8% (40 of 5123 cultures) in optional-to-routine sterile gloving if possible contaminants were included (P _ 0.30). The contamination rate was 0.7% (40 of 5397 cultures) in routine-to-optional sterile gloving and 0.6% (31 of 5123 cultures) in optional-toroutine sterile gloving if only likely contaminants were in cluded (P _ 0.40). The mean contamination rates by interns were 1.0% (SD, 1.0%; interquartile range, 0% to 1.5%) if possible contaminants were included and 1.0% (SD, 0.7%; interquartile range, 0% to 1.1%) if only likely contaminants were included. Generalized mixed models demonstrated significant differences in contamination rates between routine and optional sterile gloving, regardless of the classification into contaminants or pathogens. When possible contaminants were included, the contamination rate was 0.6% in routine sterile gloving and 1.1% in optional sterile gloving (adjusted odds ratio, 0.57 [95% CI, 0.37 to 0.87]; P _ 0.009). If only likely contaminants were included, the contamination rate was 0.5% in routine sterile gloving and 0.9% in optional sterile gloving (adjusted odds ratio, 0.51 [CI, 0.31 to 0.83]; P _ 0.007).
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Adherence to Gloving Methods
The interns reported the actual gloving methods for 8082 (76.8%) of 10 520 blood cultures. The reporting rate for the actual gloving methods used was 76.3% (5363 of 7027 cultures) in general wards, 80.5% (1968 of 2446 cultures) in hematology wards, and 71.7% (751 of 1047 cultures) in the intensive care unit (P _ 0.133). The reporting rate was 76.8% (4045 of 5265 cultures) in routine sterile gloving and 76.8% (4037 of 5255 cultures) in optional sterile gloving (P _ 0.54). No statistically significant difference was found in contamination rates between blood cultures obtained with or without known gloving methods (0.8% vs. 0.9% [P _ 0.39] if possible contaminants were included and 0.7% vs. 0.7% [P _ 0.88] if only likely contaminants were included).

During routine sterile gloving, 3791 (93.7%) of 4045 blood cultures were done wearing sterile gloves, whereas in optional sterile gloving, 296 (7.3%) of 4037 blood cultures were carried out with sterile gloving. The adherence rate to sterile gloving during the routine gloving period was 92.3% (1973 of 2138) in the routine-to-optional sterile gloving group and 95.3% (1818 of 1907) in the optionalto- routine sterile gloving group (P _ 0.68). In optional sterile gloving, sterile gloves were worn for 2.8% of blood draws (55 of 1977) in the routine-to-optional sterile gloving group and 11.7% (241 of 2060) in the optional-toroutine sterile gloving group (P _ 0.001). In routine sterile gloving, the adherence rate to sterile gloving was 93.9% (2520 of 2685) in general wards, 92.8% (925 of 997) in hematology wards, and 95.3% (346 of 363) in the intensive care unit (P _ 0.006). In optional sterile gloving, sterile gloves were worn for 7.8% (209 of 2678) of blood draws in general wards, 8.0% (78 of 971) in hematology wards, and 2.3% (9 of 388) in the intensive care unit (P _ 0.001).

From 301 patients, we identified 673 positive blood cultures; 244 isolates from 216 single positive blood cultures (185 patients) were classified into 67 cases of (36.5%) likely contaminants, 22 (12.8%) possible contaminants, and 155 (50.7%) true pathogens. The main organisms of likely or possible contaminants (89 cases [100%]) were coagulase-negative Staphylococcus (52 cases [58.4%]), Bacillus species (10 cases [11.2%]), and Enterococcus species (9 cases [10.1%]). The overall contamination rate was 0.9% (94 of 10 520 cultures) if possible contaminants were included and 0.7% (71 of 10 520 cultures) if only likely contaminants were included. The contamination rate based on hospital unit was 1.0% (69 of 7027 cultures) in general wards, 0.4% (11 of 2446 cultures) in hematology wards, and 1.3% (14 of 1047 cultures) in the intensive care unit if possible contaminants (P _ 0.039) were included and 0.8% (56 of 7027 cultures) in general wards, 0.4% (9 of 2446 cultures) in hematology wards, and 0.6% (6 of 1047 cultures) in the intensive care unit if only likely contaminants were included (P _ 0.107). The contamination rate based on gloving method sequence was 1.0% (54 of 5397 cultures) in routine-tooptional sterile gloving and 0.8% (40 of 5123 cultures) in optional-to-routine sterile gloving if possible contaminants were included (P _ 0.30). The contamination rate was 0.7% (40 of 5397 cultures) in routine-to-optional sterile gloving and 0.6% (31 of 5123 cultures) in optional-toroutine sterile gloving if only likely contaminants were in cluded (P _ 0.40). The mean contamination rates by interns were 1.0% (SD, 1.0%; interquartile range, 0% to 1.5%) if possible contaminants were included and 1.0% (SD, 0.7%; interquartile range, 0% to 1.1%) if only likely contaminants were included. Generalized mixed models demonstrated significant differences in contamination rates between routine and optional sterile gloving, regardless of the classification into contaminants or pathogens. When possible contaminants were included, the contamination rate was 0.6% in routine sterile gloving and 1.1% in optional sterile gloving (adjusted odds ratio, 0.57 [95% CI, 0.37 to 0.87]; P _ 0.009). If only likely contaminants were included, the contamination rate was 0.5% in routine sterile gloving and 0.9% in optional sterile gloving (adjusted odds ratio, 0.51 [CI, 0.31 to 0.83]; P _ 0.007).

Adherence to Gloving Methods
The interns reported the actual gloving methods for 8082 (76.8%) of 10 520 blood cultures. The reporting rate for the actual gloving methods used was 76.3% (5363 of 7027 cultures) in general wards, 80.5% (1968 of 2446 cultures) in hematology wards, and 71.7% (751 of 1047 cultures) in the intensive care unit (P _ 0.133). The reporting rate was 76.8% (4045 of 5265 cultures) in routine sterile gloving and 76.8% (4037 of 5255 cultures) in optional sterile gloving (P _ 0.54). No statistically significant difference was found in contamination rates between blood cultures obtained with or without known gloving methods (0.8% vs. 0.9% [P _ 0.39] if possible contaminants were included and 0.7% vs. 0.7% [P _ 0.88] if only likely contaminants
were included).

Our study was designed to determine whether routine sterile gloving during blood culture collection reduces blood culture contamination rates. The sample size necessary to detect a 2-fold decrease in the contamination rate was calculated. We assumed that the contamination rate in the study hospital would be 1%, resulting in 9400 blood cultures being required to detect a difference of this magnitude (power, 0.8; type I error, 5%). Therefore, 6 months was determined to be the study period on the basis of the usual frequency of blood cultures in the study hospital. The difference in blood culture contamination rates was evaluated according to the original group assignment, regardless of the actual gloving methods, by using generalized mixed models with binary outcome. In each model, the patient and intern were included as random effects because of a possible clustering effect by these factors. Gloving method, hospitalization unit, and sequence of gloving methods (routine-to-optional or optional-to-routine) were included as fixed effects. The interaction between gloving method and hospitalization unit or between the sequence and hospitalization unit was not significant. The differences in adherence to the assigned gloving methods and reporting rates for the actual gloving methods used were evaluated by using generalized mixed models with binary outcomes. In these models, the intern was included as a random effect and gloving method, hospitalization unit, and sequence of gloving methods were included as fixed effects. We used the chi-square test to compare the distribution of blood cultures according to hospitalization unit between routine and optional sterile gloving. The statistical analyses using generalized mixed models were done by using SAS software, version 9.2 (SAS Institute, Cary, North Carolina). Other statistical analyses and randomization were done by using SPSS software, version 17.0 (SPSS, Chicago, Illinois). All tests were 2-tailed. A P value less than 0.05 was considered statistically significant. The institutional review board at Seoul National University Hospital approved the study protocol.

RESULTS
Baseline Characteristics
All 64 interns placed in the medical wards during the study period participated. A total of 10 520 blood cultures from 1854 patients were analyzed, comprising 5265 blood cultures from the routine sterile gloving period and 5255 blood cultures from the optional sterile gloving period. The number of blood cultures from each hospital unit was 7027 (66.7%) from general wards, 2446 (23.2%) from hematology wards, and 1047 (9.9%) from the intensive care unit. No significant difference between the routine and optional sterile gloving groups was found in the distribution of blood cultures according to unit (P _ 0.55). The mean number of blood cultures done by an individual intern was 164 (SD, 66; interquartile range, 116 to 193).

The skin disinfectant consisted of 10% aqueous povidoneiodine, and the rubber septums on the blood culture bottles were disinfected with 70% isopropyl alcohol. Without use of needle change methods, blood specimens were inoculated into both aerobic and anaerobic vials of blood culture media (BacT/ALERT FA and FN, bio- Me´rieux, Durham, North Carolina). Blood cultures were incubated at 37 °C for 7 days. Organisms and their susceptibilities to antibiotics were identified by using automated methods and standard criteria (Microscan WalkAway-96, Siemens Healthcare Diagnostics, Deerfield, Illinois). The interns were instructed to record actual gloving methods for an individual patient to investigate their adherence to gloving methods.

Classification of Blood Culture Isolates
At our hospital laboratory, blood culture bottles are only accepted in paired sets, consisting of an anaerobic bottle and an aerobic bottle. According to the current blood culture guidelines, 2 or 3 sets of blood are routinely drawn when blood culture is needed. If any organism was isolated from any bottle in a blood culture set, it was considered a positive blood culture. If an organism was isolated from only 1 set of 2 or more blood cultures done from 1 blood collection, it was considered a single positive blood culture. For example, if 2 sets of blood cultures were done from 1 blood collection and Staphylococcus aureus was isolated from 2 sets, that episode was counted as 2 positive blood cultures and no single positive blood culture. If the same organism was isolated from only 1 set of cultures, it was counted as 1 positive blood culture and 1 single positive blood culture. In cases of polymicrobial cultures, if any isolated organism was classified as a likely or possible contaminant, the blood culture was regarded as a single contaminated culture for calculating contamination rates. Three infectious disease specialists who were blinded to the intern assignments independently classified each isolate from single positive blood cultures as likely contami nant, possible contaminant, or true pathogen. If all 3 opinions were different, that of another infectious disease specialist was obtained. Final decisions were made by a majority rule. Likely contaminants were common skin flora, including Bacillus species, coagulase-negative staphylococci, Corynebacterium species, Enterococcus species, Micrococcus species, Propionibacterium species, or viridans Streptococcus, without isolation of the identical organism with the same antibiotic susceptibility from another potentially infected site in a patient with incompatible clinical features and no attributable risks. True pathogens were defined as enteric gram-negative bacilli, Pseudomonas species, S. pyogenes, S. pneumoniae, Bacteroides species, and Candida species or by obtaining an identical organism with the same antibiotic susceptibility from another potentially infected site and the organism could account for the clinical features of the patient. Possible contaminants were defined as isolates obtained from 1 set of blood cultures that did not meet the criteria for likely contaminants or true pathogens.

Blood culture is a simple and basic diagnostic procedure routinely used in clinical practice that yields essential information for the evaluation of various infectious diseases. A positive blood culture can demonstrate not only an infectious cause of disease but also a microbiological response to antibiotic therapy. However, studies have reported that 35% to 50% of positive blood cultures are falsely positive owing to contamination. False-positive cultures often cause serious interpretation problems, leading to the use of inappropriate or unnecessary antibiotics, additional testing and consultation, and increased length of stay, all of which increase health care costs. In a closed culture system in which blood is drawn directly into vacuum culture bottles, blood culture contamination occurs mainly during specimen collection. Various methods have been widely studied to reduce contamination rates, including skin disinfectants, source of culture, specialized phlebotomists, and changing of needles before inoculating culture bottles. To our knowledge, no data are available on the influence of sterile gloving on blood culture contamination rates. Consequently, some controversy exists about whether sterile gloving should be routinely used during collection of blood for culture. The current guidelines do not recommend the routine use of sterile gloving, whereas some experts prefer sterile gloving for collection of blood for culture. We sought to evaluate whether the routine use of sterile gloving before venipuncture reduces blood culture contamination rates compared with the optional use of sterile gloving in actual clinical practice.

Study Design
We conducted a prospective, cluster randomized, assessor-blinded, crossover, controlled trial. Our study was conducted for 6 months in 2009 in 17 medical wards, including 14 general wards, 2 hematology wards, and 1 intensive care unit at Seoul National University Hospital, a 1600-bed, university-affiliated tertiary-care teaching hospital in Seoul, Republic of Korea. At this hospital, medical interns rather than dedicated phlebotomists are in charge of drawing blood for cultures. We did not include the emergency department because the emergency medical technicians, as well as interns, draw blood for culture in the emergency department. The interns in the hospital were rotated from one department to another each month. The interns in the medical wards consented to participate in the study and took part in the study for 1 month. In each month, 6 to 7 interns were in charge of the 14 general wards, 2 interns in the 2 hematology wards and 2 interns in the intensive care unit. We included all cultures using blood drawn from a peripheral vein in adult patients who needed 2 or more sets of blood cultures, and we excluded blood cultures from intravenous lines and similar access devices. Consent was obtained from all participating interns.

Patients seeking immediate care for medical conditions in San Francisco have many options during normal weekday hours. There are several immediate care clinics located throughout the city, and hospitals usually have what is equivalent to an immediate care clinic attached to their emergency department. Once patients determine what options are available they can further narrow down the choices according to proximity, wait times and, of course insurances accepted.

While ER’s tend to accept many insurance plans, a co-payment is usually required and will depend upon the individual policy. Waiting times in emergency rooms are always unpredictable, however there are trends to be aware of for those requiring care in the ER. Mornings are variable, but typically see lower volumes than afternoons and evenings, although there is never a guarantee, and the number of patients presenting to an ER often changes moment to moment. Late evenings and nights until 2-3am are the prime time in many emergency departments and so waits can be prolonged.

During these times ER staff may be routinely increased to handle the extra volume. Some hospitals maintain functioning immediate care clinics only during these hours, in order to take the pressure off of the emergency room. This can speed patient throughput, however there is never a guarantee. An emergency department that appears slow, may become chaotic within minutes if several seriously I’ll patients arrive concurrently. Emergency departments sometimes go on”divert” status, which means that ambulances transporting new patients are diverted to other facilities because the ER is overwhelmed.

In some cases, it is possible to call ahead to a particular ER to determine if it is on “divert”. If so, this may be a good time to choose another hospital, however if the problem is serious or potentially life threatening, the closest hospital ER should always be the destination. To find an immediate care clinic, an online search via Google Maps is a quick way to note the options.

A revolutionary alternative to the immediate care clinic are urgent care doctor house calls. These services offer exceptional convenience by bringing the doctor, medications, procedures, instant tests, xrays and more directly to patients wherever they are. There are no public waiting rooms to endure, and fees are far less than those of most emergency rooms. Services offered are often insurance reimbursable to a significant degree.

Many patients are finding that the convenience offered by services of this nature is unsurpassed, so that finding an immediate care clinic is no longer necessary. They prefer to let the doctor find the patient instead.

Autopsy studies and examinations of inflamed gall bladders removed surgically show that bacteria are rarely involved. Inflammation of the gall bladder can be caused by drugs, chemicals and bacterial toxins,6 in which case the liver should be built up to the extent that such substances can be detoxified. Two sisters who incurred this type of gall-bladder inflammation from spraying roses recently reported a rapid recovery after taking 1,000 milligrams of vitamin C and 200 units of vitamin E every three hours with pep-up containing 4 egg yolks per quart.

Usually, inflammation occurs only when cortisone is not being produced in adequate amounts; hence emphasis must be placed on helping the adrenals function with maximum efficiency.

Jaundice

When pigments from the breakdown of worn out red blood cells, excreted in bile as a waste product, cannot reach the intestine, they accumulate in the blood and are deposited in the tissues, thus giving the skin and whites of the eyes the yellow coloring characteristic of jaundice. Any condition that causes a rapid destruction of red blood cells can bring on jaundice, but more often the disease results from severe swelling or spasms of the bile duct, surgical trauma, or obstruction caused by a cancer, stone or cyst that prevents the bile from reaching the intestine.

During World War II, when jaundice was a chief cause of illness, army doctors found that recovery could be markedly speeded up by a diet extremely high in protein (250 grams daily) provided the patient could consume such a huge amount. Fats were not limited, and carbohydrates were generously supplied to prevent proteins from being used for calories. Most authorities have recommended 100 to 150 grams of protein daily with a diet moderate in fat and rich in natural starches and sugars. During jaundice, the backing up of bile acids into the blood breaks down fat in the walls of the red blood cells, thus causing anemia. For this reason, the diet should be high in all nutrients needed to rebuild blood. If the diet is faulty, severe liver damage or even cirrhosis may occur; therefore adequate nutrition should be continued long after recovery.

When jaundice is brought on by spasms of the tiny muscles of the bile duct, nutrients that aid tissue relaxation should be immediately emphasized: vitamin B6, magnesium, calcium, and sufficient vitamin D to insure calcium absorption. To stimulate cortisone production, the anti-stress formula should be taken with highly fortified milk around the clock. When these measures cannot be started quickly enough, bile is sometimes forced into the pancreas, where it can cause severe inflammation, acute pain, and hemorrhage. If pancreatitis does develop, an anti-stress diet rich in the above nutrients should be given as soon as the patient is able to retain food.

Diet for Gall-Bladder Abnormalities

At the onset of hepatitis, pancreatitis, an inflammation of the gall bladder, or when a stone first obstructs the bile duct, nausea and vomiting usually become so severe that little food can be eaten. A physician should be called immediately. Every effort should be made, however, to prevent acidosis and to meet the demands of stress.

After the acute stage has passed, small two-hour feedings are gradually replaced by six light meals daily. The bile flow is inadequate during most diseases of the gall bladder, but lecithin can be taken to homogenize fats, thus increasing their absorption. Though bile acids, necessary to taxi digested fats and fat-soluble vitamins across the intestinal wall, can be increased 100 per cent by using oils instead of solid fats, they should be supplied temporarily by tablets of dried bile. Generally a teaspoon of lecithin and 1 to 3 tablets of dried bile with enzymes per meal and mid-meal are sufficient to assure efficient digestion and prevent gas formation. Soft stools would indicate that enough bile is being obtained and that insoluble soaps are not being formed. Because the blood levels of vitamins A, D, and E are especially low during diseases of the gall bladder, these fat-soluble vitamins should be taken with the lecithin and bile.

Gas distention can be further reduced by taking 1 or 2 cups of yogurt or acidophilus milk daily. If an odor to the stool persists, indicating that protein digestion is still incomplete, lecithin, yogurt or acidophilus, and bile tablets with enzymes should all be increased; and conversely, when no digestive disturbances occur, amounts of these foods may be decreased and the tablets discontinued.

Diets for gall-bladder diseases usually have a long list of “avoids,” for which there appears to be no scientific basis. Actually, no food need be forgone as long as it builds health; even salads are not taboo. To stimulate bile flow, no less than a teaspoon of oil should be obtained at each meal and mid-meal, always used appetizingly in food. At first milk and milk soups, whole-grain breads and cereals, lean meats and fish, eggs, cottage cheese, fruits, vegetables, custards, and simple milk desserts are customarily allowed. When weight permits and recovery is well under way, small servings of pork, steak, gravies, and gently fried foods can usually be eaten without discomfort provided lecithin and bile tablets are taken at each meal.

To obtain a high-protein diet needed for repair without getting excessive amounts of saturated fats, one can rely on yeast, soy flour, wheat germ, fresh and powdered skim milk, nuts, non-hydrogenated nut butters, and liver lightly sautéed in oil. Many of these high-protein foods can be incorporated into delicious breads, waffles, muffins, and hotcakes baked on a dry griddle.