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COLDS

COLDS. The COMMON Cold. #1 REASON for visits to physicians, #3 for internists 27 million physician visits per year 23 million days of work missed Average adult has 2-4 colds per year $3 billion spent per year on OTC remedies. Epidemiology. September through May

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COLDS

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  1. COLDS

  2. TheCOMMONCold • #1 REASON for visits to physicians, #3 for internists • 27 million physician visits per year • 23 million days of work missed • Average adult has 2-4 colds per year • $3 billion spent per year on OTC remedies

  3. Epidemiology • September through May • Spread by hand-to-hand contact and aerosols

  4. Microbiology _____________________________________ Virus % of cases Rhinovirus 30-40 Coronavirus 10-15 RSV Influenza Parainfluenza Adenovirus Unkown 25-40

  5. Pathogenesis • ICAM • Rhinosinusitis • Histology of Nasal Epithelium is Normal • Increased vascular permeability and secretions • Components of Snot • Role of PMNs, Histamine, Kinins, IL

  6. Approach to the common cold________________________________________________________________________ • H & P • Diagnosis - consider complications, flu allergy, strep • Ascertain Expectations • Reassure (but don’t minimize) • Express sympathy • Educate • Offer symptomatic relief

  7. H & P SymptomFrequencyDay Nasal 45 to 75% 1 - 2 Discharge Sneezing Obstruction Pharyngeal 35 to 50% 2 - 3 Sore Throat Scratch Throat Cough 40 to 80% 2 -14 Hoarse 15 to 30% 2 - 14 Constitutional 2 - 4 Feverish Myalgia Headache

  8. Consider Complications • Bronchitis • Sinusitis • Otitis Media • Pneumonia • Bronchospasm

  9. THE TRUE BLUE FLUEpidemiology • Usually peaks in January or later • 20,000 deaths in a typical epidemic season • 110,000 hospitalizations • 10%-20% of population infected during typical season • When flu epidemic in region, high percentage of those with ILI have flu

  10. THE TRUE BLUE FLUClinical Presentation • Classic Flu - sudden onset prostration, high fever, nasal stuffiness, sore throat, myalgia, cough and headache • Study Flu - usually fever + 2 symptoms • Illness resolves over four to five days • Cough, fatigue, malaise can linger 2-3 weeks • Complications - bacterial tracheobronchitis, sinsusitis, pneumonia

  11. Symptom Fever (> 37.8) Feverishness Cough Nasal congestion Weakness Loss of Appetite Sore Throat Headache Myalgia With fluWithout flu 68 40 90 89 93 80 91 81 94 94 92 86 84 84 91 89 94 94 DIAGNOSIS OF INFLUENZAAre there pathognomonic symtpoms?Proportion of patients with symptom

  12. DIAGNOSIS OF INFLUENZAAre there pathognomonic symtpoms? USE OF A CASE DEFINITION AS A DIAGNOSTIC TOOL 100 patients with a flu-like illness: T > 37.8 plus 2 of 4: cough, myalgia, sore throat, headache Case Definition: T > 38 + cough during flu season Positive Predictive Value 86.8% Negative Predictive Value 39.3% Sensitivity 77.6% Specificity 55.0% __________________________

  13. DIAGNOSIS OF INFLUENZA INFLUENZA SURVEILLANCEwww.cdc.gov • WHO - worldwide tracking of drift and shift • CDC, Influenza Branch • National Respiratory and Enteric Virus Surveillance System • 122 Cities Mortality Reporting System • State and Territorial Epidemiologists Reports • US Influenza Sentinel Physicians Surveillance Network

  14. DIAGNOSIS OF INFLUENZA RAPID FLU TESTS

  15. INFLUENZA Treatment Drug Trade Name Flu Type Cost Caveat ____________________________________________________ Amantidine Symmetrel A 9.83 Resistance Generic 1.72 CNS Rimantidine Flumadine A 18.87 Resistance Zanamivir Relenza A and B 44.40 Bronchospasm Oseltamivir Tamiflu A and B 53.00 GI

  16. INFLUENZA Prophylaxis • VACCINATE • EXPOSURES • LONGTERM CARE FACILITIES

  17. Approach to the common cold________________________________________________________________________ • H & P • Diagnosis - consider flu, bacterial complications, allergy, strep • Ascertain Expectations • Reassure (but don’t minimize) • Express sympathy • Educate • Offer symptomatic relief

  18. Patients’ Understanding of the Common Cold * 87% of people do not seek care for their colds * In a survey of young adults 94% said it was not necessary to go to a doctor for a cold. On the other hand * Of patients in a clinic for other reasons, 61% said they would seek care for 5days rhinorrhea, cough, sore throat; if the discharge were discolored, 79% would seek care. * 87% of a sample in England thought antibiotics were beneficial for a cold. a

  19. Patients’ Understanding of the Common Cold What Causes a Cold? Virus 43.5% Virus and Bacteria 41.9% Bacteria 7.9% Don’t Know 6.7% Antibiotics are helpful for colds Strongly Agree 18.2% Agree 26.1% Disagree 17.2% Strongly Disagree 31.4% Don’t know 7.1% aa

  20. Factors Correlating with a Desire for Antibiotics • Previous Rx for Antibiotic for URI • Belief they work • Purulent secretions • Medicaid • From a country where abx are OTC

  21. Why not give antibiotics? Biggest Risk Factor for developing resistant S.pneumonia is previous exposure to abx Good studies show that when overall antibiotic prescribing is reduced, the prevalence of resistant strains drops. About 30% of all the antibiotics prescribed in the US are for outpatient colds. In many studies, patients with clear cut colds are Rxed abx 50-60% of the time. They don’t work a

  22. A Multidimensional Intervention to Reducing Rxs For Antibiotics • For “Bronchitis” • Preliminary study found that clinicians code according to Rx given, not symptoms. The dx of “chest cold” rather than “bronchitis” lowered expectations for abx • Patient and clinician education • Reduced Rxs for bronchitis from 74% to 48%

  23. Symptomatic Treatment SymptomTreatments Congestion Topical Decongestant Oral Decongestant Rhinorrhea Anticholinergic Sneezing Antihistamine Cough Suppressant Tx for Rhinorrhea Constitutional Acetaminophen ASA, NSAID Sore Throat Gargles, Lozenges Analgesia a

  24. Remedies • Zinc Gluconate • Vitamin C • Chicken Soup • Vapors

  25. You’ve got the worst cold I’ve seen all day

  26. Are you miserable?You look miserable.

  27. I wish we had better treatmentsfor bad colds

  28. but as you knowthere’s no cure yet

  29. Your cold comes from aviralinfection.

  30. Unfortunately,

  31. And furthermore,

  32. YOUR body will fight this off just like it’s always done.

  33. Your body’s immune system works bestwhen yougive it plenty of rest

  34. In the meantime, let’s see if we can treat the symptoms so you’re not suffering so much.

  35. If it’s helping, keep taking the oil of newt

  36. If you get worse,

  37. I HOPE YOU FEEL BETTER SOON

  38. bye

  39. NO I AM NOTJUST GOING TO GIVE YOU THE ANTIBIOTICS

  40. Approach to the common cold________________________________________________________________________ • H & P • Diagnosis - consider flu, bacterial complications, allergy, strep • Ascertain Expectations • Reassure (but don’t minimize) • Express sympathy • Educate • Offer symptomatic relief

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