 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / Diseases and Disorders / Asthma / April 2005long term prednisone therapy ????
I have struggled with a sinus infection that started 4 years ago after about 1 year my lungs became infected ..this started a roller coaster health ride for me ...many antibiotics , inhalers, and way too much predisone ,,,pred use was almost constant the last 3 years ...anyway seems alot of you here have similar troubles. I found the following on the web the interesting thing is long term prednisone use depresses the immune system leading to opertunistic infections the biggie is PCP. I talked my Dr. into a rx for bactrim ...what a drastic change for the better..lungs are clear and sinus is the best its been for 3 years.. I'm still taking bactrim so I am hoping the sinus also totally clears we'll see....so here is some food for thought. ....Michael Bactrim, an antibacterial combination drug, is prescribed for the treatment of certain urinary tract infections, severe middle ear infections in children, long-lasting or frequently recurring bronchitis in adults that has increased in seriousness, inflammation of the intestine due to a severe bacterial infection, and travelers' diarrhea in adults. Bactrim is also prescribed for the treatment of Pneumocystis carinii pneumonia, and for prevention of this type of pneumonia in people with weakened immune systems. -------------------------------------------------------------------------------- Most important fact about this drug Return to top Sulfamethoxazole, an ingredient in Bactrim, is one of a group of drugs called sulfonamides, which prevent the growth of bacteria in the body. Rare but sometimes fatal reactions have occurred with use of sulfonamides. These reactions include Stevens-Johnson syndrome (severe eruptions around the mouth, anus, or eyes), progressive disintegration of the outer layer of the skin, sudden and severe liver damage, a severe blood disorder (agranulocytosis), and a lack of red and white blood cells because of a bone marrow disorder. Notify your doctor at the first sign of an adverse reaction such as skin rash, sore throat, fever, joint pain, cough, shortness of breath, abnormal skin paleness, reddish or purplish skin spots, or yellowing of the skin or whites of the eyes. Frequent blood counts by a doctor are recommended for patients taking sulfonamide drugs. Treatment of Pneumocystis Carinii Pneumonia The recommended dosage is 15 to 20 milligrams of trimethoprim and 75 to 100 milligrams of sulfamethoxazole per 2.2 pounds of body weight per 24 hours divided into equal doses every 6 hours for 14 to 21 days. For the treatment of Pneumocystis carinii pneumonia (PCP): a.. Adults and children older than 2 months-Dose is based on body weight. The usual dose is 18.75 to 25 mg of sulfamethoxazole and 3.75 to 5 mg of trimethoprim per kg (8.5 to 11.4 mg of sulfamethoxazole and 1.7 to 2.3 mg of trimethoprim per pound) of body weight every six hours. Causes: PCP occurs only in immunocompromised individuals, particularly patients with cell-mediated immune deficiencies. Patients at risk include the following: a.. Persons infected with HIV a.. CD4 count less than 200 and not on PCP prophylaxis a.. Evidence of oropharyngeal thrush or fever, regardless of CD4 count a.. Patients with HIV who have undergone splenectomy - May have spuriously high CD4 count a.. Patients with hematologic malignancies a.. Patients on long-term steroids or immunosuppressant therapy, including patients with systemic vasculitis or other autoimmune diseases a.. Organ-transplant recipients a.. Patients with other immune deficiencies a.. Thymic dysplasia a.. Severe combined immunodeficiency a.. Hypogammaglobulinemia a.. Patients with severe malnutrition I doubt chronic PCP issues were causing your symptoms. You have to be pretty darned immunosuppressed for that. It usually requires end stage HIV (it is an AIDS defining illness), a combination of high dose prednisone and other immunosuppressants, or some other severe immunodeficiency. It may have been chronic sinus issues that are finally being addressed. Just in case anyone is wondering - Bactrim would not normally be expected to kill mycoplasma and chlamydia.  Signature00doc 00doc : Yours is the attitude reflected by my prior doctors , which is why I believe this was overlooked ...only recently end of 2004 have medical studies shown the link between long term predisone therapy and PCP... So In this age of try this one then switch to that one antibioatic therapy practiced by doctors ...I'm suggesting if that hasn't helped improve your health just remind your doctors of bactrim and show them the studies (google search) .....bactrim has been around along time and is cheap but very effective for some inlight of the new studies.....Mahalo Michael >I doubt chronic PCP issues were causing your symptoms. You have to be > pretty darned immunosuppressed for that. It usually requires end stage [quoted text clipped - 5 lines] > Just in case anyone is wondering - Bactrim would not normally be > expected to kill mycoplasma and chlamydia. > 00doc : Yours is the attitude reflected by my prior > doctors , which [quoted text clipped - 13 lines] > some > inlight of the new studies.....Mahalo Michael "00doc" What you should realize is that it can be diffuicult to seperate whether the PCP is a harmless colonizer versus and out of control infection. Response to Bactrim is not sufficient alone since, as I pointed out, it may be having several different effects besides killing PCP. The other thing you should realise is that by analogy to other immunosuppressed states if yuo do have a PCP issue then you will need to take Bactrim prophylaxis for as long as you are similarly immunocompromised. if you can stop the bactrim while still on the prednisone than the issue was probably not PCP (or for some reason it is behaving differently then it does in other examples). Signature00doc > 00doc : Yours is the attitude reflected by my prior > doctors , which [quoted text clipped - 3 lines] > predisone > therapy and PCP... OK - I did searches on several different databases. I found a few case reports (and you have to go back years to make it as many as a few) of asthmatics getting full blown PC pneumonia while on high doses of systemic steroids. I found one case report of two people who presented with asthma symptoms that were determined to be PC and who were then diagnosed with AIDS. I didn't find any "links" between the two in the sense of asthmatics wheezing for prolonged periods and having it later discovered that the problem was undiagnosed PC (except for the two guys with AIDS). Maybe you could show us these links you are referring to. Signature00doc I'll direct you to the study from 2004 when I find it again,,but the case studies below take us down the path......PCP and Prednisone......mahalo Michael Heart Lung. 2002 Jan-Feb;31(1):50-2. Related Articles, Links Pneumocystis carinii pneumonia presenting as a fever of unknown origin in a patient without AIDS. Jani K, Mehta NJ. State University of New York Health Science Center, Division of Pulmonary and Critical Care Medicine, Brooklyn, USA. Pneumocystis Carinii pneumonia (PCP) remains an opportunistic infection that causes substantial morbidity and mortality in patients who have impaired immune function. PCP in patients who do not have AIDS usually manifests in a more fulminant manner than in patients with AIDS. In recent years, PCP has been reported increasingly in patients with connective tissue disorders. The role of corticosteroids in inducing PCP is well established in humans and animals, though information is currently lacking about the exact mechanism of induction, frequency, dosage, and duration of corticosteroid therapy that predisposes the development of PCP across a variety of patient groups. Until earlier diagnosis and a better understanding of who is at risk are readily available, health care providers need to consider the diagnosis of PCP early in the clinical course of any patient who receives systemic steroid therapy. We report a case of PCP in a patient who took oral steroid treatment for 2 months for suspected connective tissue disorder. The patient presented with a fever of unknown origin. The case is unusual because the patient's serial chest x-ray and gallium scan yielded normal findings and no suggestive respiratory signs or symptoms were found. The only suggestive finding was a consistently elevated serum lactate dehydrogenase level. The diagnosis was established by the identification of Pneumocystic carinii in bronchoalveolar lavage fluid. Publication Types: a.. Case Reports PMID: 11805750 [PubMed - indexed for MEDLINE] Infection. 2000 Jul-Aug;28(4):227-30. Related Articles, Links Pneumocystis carinii pneumonia as a complication of immunosuppressive therapy. Gluck T, Geerdes-Fenge HF, Straub RH, Raffenberg M, Lang B, Lode H, Scholmerich J. Dept. of Internal Medicine I, University Medical Center, University of Regensburg, Germany. thomas.glueck@Klinik.uni-regensburg.de BACKGROUND: Patients receiving immunosuppressive therapy with corticosteroids and cytotoxic agents may develop opportunistic infections such as Pneumocystis carinii pneumonia (PCP). This indicates a severe T-cell defect, but so far there are no established criteria for identifying patients at risk. PATIENTS AND METHODS: CD4+ and CD8+ T-lymphocyte counts were determined by flow cytometry in seven HIV-negative patients who developed PCP as a complication of immunosuppressive treatment. RESULTS: CD4+ T-lymphocyte counts (T-helper phenotype) were less than 200/microl in all seven patients (mean 90.6/microl). The markedly reduced CD4 counts measured in these patients are similar to those observed in organ transplant recipients who developed PCP during immunosuppressive therapy for prevention of graft rejection and in HIV-positive patients with PCP as an AIDS-defining illness. CONCLUSION: Measuring CD4+ T-lymphocyte counts may be helpful in determining the risk of PCP not only in HIV-positive patients, but also in patients receiving immunosuppressive therapy. The risk of acquiring PCP seems to increase when CD4+ lymphocyte counts drop below 200/microl, regardless of the underlying disease. Publication Types: a.. Case Reports PMID: 10961529 [PubMed - indexed for MEDLINE] Rheumatology (Oxford). 2004 Apr;43(4):479-85. Epub 2004 Feb 3. RESULTS: Detection of P. carinii DNA by PCR was significantly more sensitive than cytology; 54.5% patients were positive by PCR and only 4.5% by cytology. The prevalence of PCP was higher than previously considered and was especially high in patients receiving > 30 mg/day prednisolone with or without other immunosuppressants. CONCLUSIONS: PCP may complicate a variety of immunocompromised states especially autoimmune diseases and hematologic malignancy. Patients who receive corticosteroids and/or cytotoxic drugs should receive primary PCP prophylaxis. The mortality rate is high especially in severe cases that need mechanical ventilation. Intensive care and close monitoring are needed for these patients. PMID: 12948254 [PubMed - indexed for MEDLINE] CONCLUSION: Although these results do not suggest that premorbid administration of corticosteroids is the only factor that contributes to the development of P. carinii pneumonia in these patients, they show that, in this large consecutive series, systemic corticosteroid therapy, even in moderate doses, was administered to most patients during the month preceding the onset of P. carinii pneumonia. Consideration should be given to instituting P. carinii prophylaxis (when not contra-indicated) in patients for whom prolonged systemic corticosteroid therapy is prescribed. PMID: 8538233 [PubMed - indexed for MEDLINE] Pneumocystis carinii pneumonia in patients with ulcerative colitis treated with corticosteroids. Bernstein CN, Kolodny M, Block E, Shanahan F. Department of Medicine, University of California, Los Angeles. Today, Pneumocystis carinii pneumonia (PCP) is typically associated with AIDS. However, in the pre-AIDS era, PCP was known to be associated with various immunodeficiency states, malignancies, and immunosuppressive therapy, particularly the use of corticosteroids. PCP has been reported to occur during immuno-suppressive therapy of some chronic inflammatory states, but it has never been reported in patients with inflammatory bowel disease. We report two patients with ulcerative colitis who developed PCP during high-dose corticosteroid therapy, and review the literature regarding non-AIDS PCP. PCP should thus be added to the list of bronchopulmonary complications in inflammatory bowel disease. This report should give gastroenterologists further impetus to limit immunosuppressive therapy to its minimal effective dose. Publication Types: a.. Case Reports PMID: 8470640 [PubMed - indexed for MEDLINE] >> 00doc : Yours is the attitude reflected by my prior >> doctors , which [quoted text clipped - 17 lines] > > Maybe you could show us these links you are referring to. > I'll direct you to the study from 2004 when I find it > again,,but the > case studies below take us down the path......PCP and > Prednisone......mahalo Michael > The patient > presented with a fever of unknown origin. The case is [quoted text clipped - 3 lines] > findings and no suggestive respiratory signs or symptoms > were found. I never said that steroids couldn't cause someone to get PC pneumonia (PCP). It is just that PCP is not likely to present as asthma. There was one case report of two guys who presented with asthma symptoms and were found to have PCP and AIDS. I haven't found any similar cases in non-AIDS paitents. Pretty much everyone other report is people who were on steroids for prolonged periods, often at high doses, and then got pneumonias which turned out to be PCP. What all this tells me is that if a steroid dependant asthmatic gets an unusual pneumonia that pneumocystis should be kept in mind. It does not support testing for it (which is hard to do) or empirically treating for it in patients with asthma symptoms but not overt pneumonia. In the case you present above the patient dit not even have respiratory symptoms so it is a bit of a stretch to use it as you are trying to do. > Pneumocystis carinii pneumonia as a complication of > immunosuppressive [quoted text clipped - 44 lines] > 200/microl, > regardless of the underlying disease. This abstract does not say what the immunosuppressive therapies were. Presumably at least some of them were on steroids - probably in combination with other things. Steroids do not normally deplete the t-cells or other white cells. If anything, the white count tends to go up on steroids. So, again, this really lends no support for what yuo are saying. > Publication Types: > a.. Case Reports [quoted text clipped - 23 lines] > care and > close monitoring are needed for these patients. Again - uncommonly high doses for chronic asthma treatment. Also they say the problem si in patients taking steroids AND/OR other cytotoxic drugs - not just steroids. Again - these were people who got pneumonia - a risk I acknowledge. There is still no mention of PCP masquerading as asthma. > CONCLUSION: Although these results do not suggest that > premorbid [quoted text clipped - 15 lines] > [PubMed - > indexed for MEDLINE] Ditto - high dose and risk of pneumonia - not mistaken ID. > Pneumocystis carinii pneumonia in patients with ulcerative > colitis [quoted text clipped - 29 lines] > immunosuppressive > therapy to its minimal effective dose. Ditto. The best you can say about hese studies is that people on high, and maybe moderate doses, of steroids might benefit from bactrim prophylaxis (more certainly if they are also taking other immunosuppressives). Bactrim has its share of problems and the morbidity seen in AIDS patients taking it chronically is not insignificant so I would be interested in seeing controlled trials of this. Nothing you have posted remotely supports the use you are touting here. Signature00doc I have struggled with a sinus infection that started 4 years ago after about 1 year my lungs became infected ..this started a roller coaster health ride for me ...many antibiotics , inhalers, and way too much predisone ,,,pred use was almost constant the last 3 years ...anyway seems alot of you here have similar troubles. I found the following on the web the interesting thing is long term prednisone use depresses the immune system leading to opertunistic infections the biggie is PCP. I talked my Dr. into a rx for bactrim ...what a drastic change for the better..lungs are clear and sinus is the best its been for 3 years.. I'm still taking bactrim so I am hoping the sinus also totally clears we'll see....so here is some food for thought. ....Michael The above is my original post .....the connection for me between asthma/prednisone/pcp is I was diagnosed by 5 different (prior) doctors with asthma , it seems when infected with pcp the toxins given off caused me to weeze so the 1st. doctor says asthma and with that diagnosis in place all the other doctors agreed and treated me for the wrong thing .....until my new doctor agreed to try bactrim. some studies indicate 30mg of prednisone daily for 2 months is all the long term necessary for some people... My original post was an alert for some other people that might be mis-diagnoised as I was . and a suggestion for them to follow this info up with their doctor... You can dive into bactrim prophylaxis and perhaps bring us all more up to date, however thats not my purpose...I know bactrim has been available for a long time and there a generic versions (cheap) Are you a doctor????? Mahalo Michael >> I'll direct you to the study from 2004 when I find it again,,but the >> case studies below take us down the path......PCP and [quoted text clipped - 127 lines] > > Nothing you have posted remotely supports the use you are touting here. "The above is my original post .....the connection for me between asthma/prednisone/pcp is I was diagnosed by 5 different (prior) doctors with asthma , it seems when infected with pcp the toxins given off caused me to weeze so the 1st. doctor says asthma and with that diagnosis in place all the other doctors agreed and treated me for the wrong thing .....until my new doctor agreed to try bactrim. " Three problems: 1) You presumably weren't on the prednisone until after you were diagnosed with asthma. You presumably would not have gotten the PCP until after being on the prednisone. So how could the PCP have caused the erroneous diagnosis of asthma? 2) If you are HIV negative and had years of asthma symptoms that turned out to be from a chronic, presumably low level, PC infection then you are the first one (at least as far as my search came up with). None of the cae reports you cite indicate anything like this. Your doctor should write it up and submit it. 3) There are more likely reasons to suppose that you may have gotten better after starting the Bactrim. Signature00doc 00doc....Hello again..... .I was on prednisone for 11 months for sinus infections along with many antibiotics ..My G P then sent me to ent to see if my new chest infection was connected to the nose problem ent says yes I think so ..so at the end of the 11 months i had my first sinus surgery and more antibiotics/prednisone .......My G P then about 2 months after the 1st sinus surgery sends me to a lung specialist who says ASTHMA .............the sinus surgeries continued 3 more times for the next two and one half years and more antibiotics/prednisone therapy............I then changed doctors and that brings this sad story current....... There is an old saying when you presume it goes something like this,,,,,when you PRE / U / ME ..when you (PRE)sume it makes an a.s outa you(U) and me (ME)..... I am getting the feeling your whole purpose is to pick things to death am I wrong.????.....Are you a doctor.?????.....Mahalo Michael > "The above is my original post .....the connection for me between > asthma/prednisone/pcp is I was diagnosed by 5 [quoted text clipped - 23 lines] > 3) There are more likely reasons to suppose that you may have gotten > better after starting the Bactrim. Michael, To answer your question, yes, he is a doctor. Joy Hello joy thank you for the answer...........it does add to my understanding that as a doctor his depth of knowledge goes well beyond mine in these issues .......but with my past experience with my prior doctors them either being too busy or perhaps being caught up in the complicated side of my infections they overlooked the simple answers Mahalo...Michael > Michael, > > To answer your question, yes, he is a doctor. > > Joy Well, it seems this is a complicated issue. And it is hard to figure out who is who when testing doesn't ID the victim (as in what exactly is going on for several particular patient). But CBI (00doc) does ask all the appropriate questions and we should all appreciate that.. And he does answer many questions here, so.......... I don't tend to put much on experiences/testamonials. Yet again, I myself have nothing nice to say about how I was treated by certain members of the medical profession ("coughing for attention" jerk doc -hope he is not PRACTICING any longer). As a matter of fact, I think someone should remove their right to practice. But that means nothing when trying to chase the causes of asthma which are varied, and that is my current focus. Answer my question on the sinus newsgroup about why you settled on this bug. If you do a search you will see I am not adverse to your theory before you think you are fighting with me. I got better on Zithromax. Joy > Hello joy > thank you for the answer...........it does add to my [quoted text clipped - 8 lines] > > > > Joy Hello joy....I have not felt we were fighting about anything ....by the way I was on zithromax also , 3 months as the blood test showed I think clamidia , doc said recent trials warranted the longer therapy ....I felt somewhat better after finishing the first two months then stayed the same thru the end of the third...but was still short on lung capacity to the point I would get winded if I went up 2 small flights of stairs thats when I talked with Doc about the prednisone and P C P studies I found on the net...He agreed then I started the bactrim and a big change......so maybe i had other issues also ,,,,,any way it's been a tough 4 years Mahalo...Michael > Well, it seems this is a complicated issue. And it is hard to figure out > who [quoted text clipped - 28 lines] >> > >> > Joy > Hello joy....I have not felt we were fighting about anything ....by the way > I was on zithromax also , 3 months as the blood test showed I think clamidia [quoted text clipped - 5 lines] > agreed then I started the bactrim and a big change......so maybe i had > other issues also ,,,,,any way it's been a tough 4 years Mahalo...Michael All you stated above makes sense to me. So you took in studies and your doc treated you based on that, but never had a positive culture? Joy "All you stated above makes sense to me. So you took in studies and your doc treated you based on that, but never had a positive culture? " You can't really do a culture or antibody tests for it. You have to get sputum from deep down (it is harder to do that it seems) and do special stains on it. I think they may also be able to do pcr on it now. You have to understand that this is not anywhere near being where Hahn et al got with his theory. His theory was much more plausible and then he went out and got data to suggest that it does happen in some appreciable percentage of asthmatics. If this guy is right he would be the first (un?)reported case ever. Basically, you have a short term study of one with no confirmation of initial infection nor documentation of cure. Signature00doc > Well, it seems this is a complicated issue. And it is hard to figure out > who [quoted text clipped - 3 lines] > answer > many questions here, so.......... forgot to add.......I always appreciate when a doctor takes the time to be involved ...00doc thank you for the time and concern....Mahalo...Michael Not that it matters. I wouldn't dismiss him because he is not nor would I expect him to fall in line behind my beliefs because I am. That's why I made a point of not answering the question. It is an interesting idea and it certainly is worth looking into. A particular patient of my partner's that I end up seeing on cross coverage int he hospital a lot comes immediately to mind and I am planning to talk to her pulmonologist about it. However, I'm thinking more along the lines of maybe we should do some tests to rule this out rather than considering it an at all comon example (she is an extreme - and present with a history more consistant with relapses of PCP then a chronic misdiagnosed infection). Signature00doc CBI, I know that the testing isn't what it could be. The way I am looking at it today is that the antibiotics took away the constant symptoms like SOB most all of the time I would not be attentive to the inhaled steroid schedule. I can remember also that Dr Enright at WebMD stated that tiredness was not a symptom of asthma, but that was certainly on my list. What I am saying is there are some "signs" I think doctors could use to ID patients like us who have an infection without waiting for the labs to rise to the occasion. Course, tiredness could be due to another medical condition. And yes it is important that you are a doc and have some clue what you are talking about. Joy > Not that it matters. I wouldn't dismiss him because he is not nor would > I expect him to fall in line behind my beliefs because I am. That's why [quoted text clipped - 9 lines] > example (she is an extreme - and present with a history more consistant > with relapses of PCP then a chronic misdiagnosed infection). I really don't want to get into a big fight about it but...... While I agree that a certain percentage of asthmatics may benefit from long term antibiotics(and it really is not known what that percentage is) and that there are certain elements of the history that would tend to suggest certain asthmatics may be more likely to benefit than others - you seem to think that all asthma symptoms are signs that suggest an indication for antibitotics. You may say otherwise here but then your actions say otherwise with you suggesting it to every person who posts. What you need to understand is that this is not the same as the mycoplasma issue. Mycoplasma and Chlamydia have been shown or is widely suspected to be capable of causing a long term subclinical infection producing a variety of symptoms whereas PC is not. MP and CP are intracellular organisms, fairly unique in the world of bacteria, so it is plausible that they could "hide" from the immune system and last for prolonged periods. PC is an extra cellular organism (they argue about exactly what it is - yeast vs protozoa (I think things are leaning toward protozoa right now)) that sets off an intense immune reaction. Also, there is a fair amount of evidence to suggest that it is likely that at least some asthmatics are harboring the infection (whereas there isn't for PC) and there are at least some trials that suggest long term benefit for at least some of these people (whereas there isn't for PC). I'm not saying that it is not known that prolonged high dose steroids can cause PCP (it is). However, it is not common - the case reports tend to get printed when they do occur. It also in the known cases tends to present with pneumonia (which is what the second "P" in PCP strands for) - the people are sick. In this case a guy without pneumonia symptoms is asking you to believe that he has steroid induced PC inducing his asthma symptoms. He insists that he is misdiagnosed - all without explaining the orginal asthma diagnosis that occured before the steroids. Sure, it is possible - but so are a lot of things without evidence to support them. It is also possible (and in my opinion more likely) that something entirely else is going on. But even all that is fairly harmless. Let him believe what he wants ot believe as long as he keeps it between him and his doc. What I am objecting to is the specific claims that he has discovered some kind of link and that other asthmatics should be badgering their docs to try prolonged courses of Bactrim (not to mention the implications that this discovery is plain to see but just being over looked by docs to busy to be bothered to read). Those conclusions are simply not supported by any shread of eivdence. Signature00doc > to suggest certain asthmatics may be more likely to benefit than others > - you seem to think that all asthma symptoms are signs that suggest an > indication for antibitotics. You may say otherwise here but then your > actions say otherwise with you suggesting it to every person who posts. I don't believe all asthma symptoms are signs and I think I stated that we are looking for tiredness, low grade fevers, adult onset particularly after an infection, asthma not triggered by allergies, constant SOB in a nonsmoker...... I am at a loss as to how you have missed this. And I think you're exaggerating when I say I have suggested it to everyone who posts. I have even stated that it wouldn't help everyone and I was sorry for that. That doesn't mean that I believe that the effective rate is in the high nineties (percentile) as some doctors have stated, but that I tend to agree with Dr Hahn that it is slightly more than half. It isn't my fault if it turns out to help people are tired of waiting and taking matters into their own hands. As a matter of fact, you might look to the medical profession and the way they stonewalled Dr Hahn for years (instead of investigating) if you want to start affixing blame. They wasted years. And if someone is tired of waiting, out of money, not able to work and having major side effects from the meds or worse, no relief from the meds, then yes, I do think they should take long term antibiotics. They MIGHT just be in the right half. I fully expect most people in the USA will have to wait for the research to conclude (and that won't happen until they get a reliable test). My assumption is that most people who visit message boards are not in the 70% who are doing well on asthma meds. > What you need to understand is that this is not the same as the > mycoplasma issue. Mycoplasma and Chlamydia have been shown or is widely [quoted text clipped - 32 lines] > looked by docs to busy to be bothered to read). Those conclusions are > simply not supported by any shread of eivdence. I agree that he hasn't a leg to stand on about the PCP. He was not confirmed to have it and the fact that Bactrim worked isn't an indication that he ever had it. However, it does stand to reason that people want to be better and they are quite frankly sick of taking steroids which (as I have stated before) don't work well or have major side effects. All this while the medical profession continues to deny to the patient who is expressing complaints that they have heard before from other patients. Just wander by any asthma message board for proof. But that aside, here is another case of someone with asthma, diagnosed by several doctors, who got better on antibiotics. Just a different one from the one Dr Hahn uses. There is the hope factor. Someone actually has gotten better. They are not faced with waiting 15 to 20 plus years. Maybe it all depends on how much your asthma impacts your life. Joy >> to suggest certain asthmatics may be more likely to >> benefit than [quoted text clipped - 15 lines] > you have > missed this. Because you have suggested that people who describe none of that try antibiotics. You have no idea how much I have been biting my tongue. > My assumption is that most people > who visit message boards are not in the 70% who are doing > well on > asthma meds. Most ? I'm not so sure. I'll grant that the sicker patients will tend to be more involved with support groups and such but I'll bet that most of the regular posters here are fairly well controlled. Signature00doc > Because you have suggested that people who describe none of > that try antibiotics. You have no idea how much I have been > biting my tongue. Links??? > > My assumption is that most people > > who visit message boards are not in the 70% who are doing [quoted text clipped - 5 lines] > but I'll bet that most of the regular posters here are > fairly well controlled. Really? That is why they spend time on it? Joy >I really don't want to get into a big fight about it but...... > [quoted text clipped - 4 lines] > that he is misdiagnosed - all without explaining the orginal asthma > diagnosis that occured before the steroids. Almost 13 months on prednisone/antibiotics/inhalers/ then sinus surgery ..then lung specialist.....my G P started treating me for asthma symptoms at about the 9th month mark then 2 months later he sent me back to ent to see if my new chest congestion could be caused by the nose problem....ent says yes then 1st sinus surgery.... Sure, it is possible - but > so are a lot of things without evidence to support them. It is also > possible (and in my opinion more likely) that something entirely else > is going on. But even all that is fairly harmless. Let him believe what > he wants ot believe as long as he keeps it between him and his doc. If I keep it between me and my doc....there occurs no conversation or exploring of these issues so basically just shut up michael go away!!! Is that really what you mean??? ........The evidence or case studies you look for to support my claim.... . wouldn't the evidence be a paper written by a doctor stating how they had overlooked something???...... How would I present or find evidence of misdiagnosis ????? I think it is more constructive to explore all possibilities openly..... > What I am objecting to is the specific claims that he has discovered > some kind of link and that other asthmatics should be badgering their > docs to try prolonged courses of Bactrim (not to mention the > implications that this discovery is plain to see but just being over > looked by docs to busy to be bothered to read). Those conclusions are > simply not supported by any shread of eivdence. If my doctor overlooked it there exists perhaps 1 or 2 others ...All doctors are not as involved and caring as you are...... I am not used to putting thoughts into written words so the chronology of my experience needs some clairifaction hope this helps. Mahalo Michael > If I keep it between me and my doc....there occurs no > conversation or > exploring of these issues so basically just shut up > michael go away!!! > Is that really what you mean??? No - but it would be nice if you had a shred of proof before popping off about being misdiagnosed and finding links etc etc. > ........The evidence or case studies you look for to > support my [quoted text clipped - 3 lines] > would I > present or find evidence of misdiagnosis ????? You could prove that you had PCP then show that the infection was cleared and that in that period of time your asthma symptoms (and objective measures of asthma severity) abated. It would make a nice case report and would be sure to be published. > I think it is more constructive to explore all > possibilities > openly..... Explore - sure. Claim a new discovery with no evidence - no. > If my doctor overlooked it there exists perhaps 1 or 2 > others ...All > doctors are not as involved and caring as you are...... See - there you go again. Who says anyone overlooked anything? Signature00doc "There is an old saying when you presume it goes something like this,,,,,when you PRE / U / ME ..when you (PRE)sume it makes an a.s outa you(U) and me (ME)..... " Actually - presuming would make a pres out of you and me - whatever that means. If you were on 11 months of steroids for sinus disease then I would say you changed doctors somewhere between 10 and 11 months too late. OK- let me tell you this. PCP in the setting of HIV usually only warrants steroids if it is severe enough to cause low oxygen levels (other than that they don't help). Even then they are usually only given for a few days (like 5 to 7) and then they are stopped. Even in the face of the ongoing immunosuppression of steroids and HIV the Bactrim only needs to be given at full doses for 2-3 weeks and then the prophylactic doses are resumed. The steroids are questionably effective in sinus disease and many ENT's specifically avoid them due to an increased risk of meningitis and parameningeal abcesses. I know some do use them but usually only in short pulses - not long term. Needless to say, the sinus disease does not present a clear reason to stay on the steroids (and may be a good reason to avoid them). If the asthma symptoms are from PC then the steroids are, again, not useful. If you think that PCP is causing your lung symptoms why not treat it like PCP? Take the Bactrim at full PCP doses - 5 mg/kg three times a day (one Bactrim DS tab has 160mg - for most adults this will be about 5-6 tabs per day) for 21 days. About 7 days into it you should be able to taper off the steroids (don't stop them abruptly if you have been on them for a long time). You should have a good clue in 3 weeks. If you need the steroids despite being on Bactrim or if you relapse while no longer immunosuppressed then it is a strong argument against PCP as the cause. If you are cured then congratulations - I'm still not sure what it proves - but I would be happy for your good health. Signature00doc I think my ENT is the only one in these past years to treat my Samters/Polyps with daily prednisone. His reasoning was this...I was using 1200 mg. during a burst which occurred at least four to six times a year. The total dosage was pretty high in the long run. We figured out 10mg. daily for four months was equal to one burst. So taking it daily gave me lower doses in the course of a year. Now we are trying to get to eod without luck though. Then the CSS started and it gave me relief from that so it looks like I will be using daily until this goes into remission. It also has kept the maxillary mucocele from getting any bigger and invading my orbit floor again. On the down side my bones are suffering. Trudy. Doc: "The steroids are questionably effective in sinus disease and many ENT's specifically avoid them due to an increased risk of meningitis and parameningeal abcesses. I know some do use them but usually only in short pulses - not long term. Needless to say, the sinus disease does not present a clear reason to stay on the steroids (and may be a good reason to avoid them)." > I think my ENT is the only one in these past years to > treat my > Samters/Polyps with daily prednisone. The polyps change things a bit. They are responsive to steroids (to some degree). This is a liitle bit different than using 11 months of steroids for a presumed but unconfirmed sinus infection. > His reasoning was this...I was > using 1200 mg. during a burst which occurred at least four [quoted text clipped - 3 lines] > figured out 10mg. daily for four months was equal to one > burst. That makes sense - but I am assuming you guys explored all other avenues of handling this and finally settled on the steroids as a last resort. This is not quite the same thing as a primary care doc "shooting forsta nd asking questions later" by putting you on long term steroids without those explorations (which he could not have done without making a referral). > So > taking it daily gave me lower doses in the course of a [quoted text clipped - 8 lines] > floor again. > On the down side my bones are suffering. Trudy. Again - you have other indications then just a clinical diagnosis of sinusitis (which is always suspect). Signature00doc > "The above is my original post .....the connection for me between > asthma/prednisone/pcp is I was diagnosed by 5 [quoted text clipped - 18 lines] > caused > the erroneous diagnosis of asthma? "PCP caused erroneous diagnosis of asthma"? Your words, not his, I think. > 2) If you are HIV negative and had years of asthma symptoms that > turned [quoted text clipped - 4 lines] > the cae reports you cite indicate anything like this. Your doctor > should write it up and submit it. He did not diagnose his asthma symptoms . . the doctors did. > 3) There are more likely reasons to suppose that you may have > gotten > better after starting the Bactrim. Indeed, he is searching for reasons why he improved dramatically after bactrim. One may be opportunistic infection following possibly excessive prednisone. PCP appears to be one. You appear to be arguing against your erroneous conclusion rather than Michaels misconception. Please read him more carefully. I came up with a number of references to PCP occurring in both HIV and non-HIV cases. . MikeV Michael...hope you are feeling better now. I have had Asthma Triad for 23 years with daily prednisone. I have never had pneumonia luckily. I also heal very well after surgery. I think Nancy is right in that if effects different people differently. I do have Osteoporsis however and am taking Actonel to restore bone. As for the Bactrim, I think there are new studies out lauding the daily use of antibiotics as a prophylactic approach for sinusitis/asthma and will try to find them. Trudy. "PCP caused erroneous diagnosis of asthma"? Your words, not his, I think. " It is an accurate paraphrase which he does not dispute. "> 2) If you are HIV negative and had years of asthma symptoms that > turned > out to be from a chronic, presumably low level, PC infection then [quoted text clipped - 3 lines] > the cae reports you cite indicate anything like this. Your doctor > should write it up and submit it. He did not diagnose his asthma symptoms . . the doctors did. " That doesn't even make sense. "Indeed, he is searching for reasons why he improved dramatically after bactrim. One may be opportunistic infection following possibly excessive prednisone. PCP appears to be one." Yep - and another is that the Bactrim is helping his sinus disease which is contributing to his respiratory symptoms. Given that we know he has sinus problems and and they can cause asthma symptoms and that this whole scenario is very common and that if he is right about the PCP thing he would be the first known case - which do you think is more likely? " You appear to be arguing against your erroneous conclusion rather than Michaels misconception. Please read him more carefully. " No - you are the one who is not reading either one of us correctly. "I came up with a number of references to PCP occurring in both HIV and non-HIV cases." The fact that you would say this shows that you are not reading either one of us very carefully. We both have posted examples of this and neither of us disputes it. However, there has never been a case report that describes this situation (at least none that I have found or he has posted). I have described the differences in detail - I suggest you go back and re-read the thread. I'm not going to go back and forth with you on this. If you post and I don't respond it will be because what you are saying has been discussed and I have nothing new to add. In that cae you should go back and read it again. Signature00doc > "PCP caused erroneous diagnosis of asthma"? Your words, not his, I > think. " > > It is an accurate paraphrase which he does not dispute. God, I hate admitting guilt. Crow for supper again. :-( I incorrectly inferred from Michael's post, (perhaps from the subject), that he thought the treatment for asthma and infections may have set up the conditions for possible PCP complication. Apologies to all for the inappropriate remarks to 00doc who not only accused of my own error, but who is clearly a thoughtful and dedicated contributor. I do not question his comments on the low probability of PCP. This appears to be a very knowledgeable and helpful group. It is actually possible to learn here, from real dicussions. Never having been a patient nor a health care professional (at 69), I fear I am not qualified for this company. However I will persist in the hope that I will learn something to help my sister in law who is currently quite ill. Summary: Former smoker, age 54, mild heart attack 8yrs ago, stent installed. Asthma began shortly after that. Past year, recurring infections, extreme violent coughing, increasing weakness. Currently hospitalized. Staph infection identified, resistant to vancomycin. Infection was said to be 'resistant' to Bactrim in a prior treatment (ten day cycle). CHF excluded. Hypogammaglobulinemic. Awaiting results on a battery of tests including fungal, possible multiple myeloma. Doctor suspects that she may have been over medicated, and has started reducing her prednisone, but she feels that this is repeating the cycle she has become familiar with. Congestion increasing, cough more productive. Family has confidence that her current doctor (internal medicine, infectious disease) is being very thorough and agressive in trying to pin down her problems. (I suspect her pulmonary and cardio docs may have been less so) I fear she is giving up hope that this can be managed. Any insights or prior experiences welcomed. No "popping-off" I promise. MikeV >> "PCP caused erroneous diagnosis of asthma"? Your words, not his, >> I [quoted text clipped - 42 lines] > > MikeV follow up on my sister in law: Multiple myelitis negative. Now on gamma globulin transfusions, and zyvox for staph, and whatever else. MikeV >>> "PCP caused erroneous diagnosis of asthma"? Your words, not his, >>> I [quoted text clipped - 48 lines] > > MikeV Sister inlaw has been sent home with situation improving. Zyvox and gammaglobulin appear to be doing the job. Internist says that failure to detect staph earlier allowed it to get out of control. It is not clear to me if other organisms were involved Bad news: 20 doses of zyvox cost about $1400. Hope she and her caregivers have learned something, and that this will not be a repeating cycle. Hope the above will help someone else avoid her situation. MikeV Hello all I have an update ....seems no pcp evidence yet if ever I dont know....doc( lung guy) looked at the xray and ct scan and says its not pcp so he took me off the Bactrim the 22nd last month,,so by the 1st i new i was getting sick and went in to see him ....doc says we need a sputim sample and for the ent to to sample sinus area AFTER I'm off the antibiotics 14 days , the ent sampeled on the 7th and put me back on bactrim cause now I'm really gettin sick ......the 11th I spent 6 hours in emergency before they felt I could go home however the er doctor asked 3 times if I didn't want to stay and made me promise to only sit and rest at home , rest was all I felt like doing.......In ER I got a large iv with avalox and prednisone while using a neb mask with albuterol for 1 solid hour then again 45 min later for another hour....Next morning my family doctor called for er update and to discuss results of ent swab test it shows Escherichia coli and Straph auresus (MARSA) infections so he says to stop avalox and start bactrim and for me to call ent to seek if any further is needed........ent nurse called back says you were given an RX ( Bactrim) so your being treated , I called family doctor back to update him he is calling an infectious disease doc for further needs ,,,, should hear tomorrow....This time the bactrim isn;t working as well or quickly not sure why ,,Any ideas????? WOW how things change in less than 3 weeks....Mahalo Michael > Next morning my family doctor called for er > update and to discuss results of ent swab test it shows [quoted text clipped - 14 lines] > things change > in less than 3 weeks....Mahalo Michael The MRSA could be developing resistance to the Bactrim as well. Bactrim (and several other older antibiotics) often work in MRSA. If they know that the Staph aureus (SA) is resistant to methicillin (and so all penicillins) (MR - MR+SA = MRSA) then they must have complete susceptibilty testing and should be able to see what to use. I cringe a bit at the ID consult. For some reason the specialists often like to use the new shiny agents despite no proven advantage. In this case it seems that all the ID guys are in love with a drug called Zyvox. It is a great drug and does kill MRSA but it really has no advantage if other less expensive agents will also kill it. I mean, the bug is either dead or it isn't. You don't get extra points for spending more money or killing it extra dead. The problems using the drug are twofold: 1) 10 days costs about $1000-1200. So to treat a sinus infection you may get away with "only $1000" but you may need several times this. As you can imagine pharmacies do not like to carry $1000 items on their shelves and insurance carriers are not fond of paying for them. So get ready for a special order and and an authorization procedure if it is recommended. [As a personal aside: If the ID guy wants it tell him to fill out the paperwork explaining why, not the PCP]. 2) It is a new and novel agent. I hate to see it used if others will do preferring to save it for when nothing else will work. Signature00doc Thanks 00doc for the feedback.....I think the ID consult is for further on the Escherichia coli as bactrim don't touch it and the ent dismissed treating it......what is you opinion to treat or not???? Mahalo Michael > I cringe a bit at the ID consult. For some reason the specialists often > like to use the new shiny agents despite no proven advantage. In this case [quoted text clipped - 14 lines] > 2) It is a new and novel agent. I hate to see it used if others will do > preferring to save it for when nothing else will work. > Thanks 00doc for the feedback.....I think the ID consult > is for [quoted text clipped - 3 lines] > treat or > not???? Mahalo E. coli shouldn't be in the sinuses so I have no idea why he would decide not to treat it. perhaps he thinks it is a contaminant? Bactrim usually would cover it unless there is a specific resistance issue. The best bet would be to look at the resistance patterns and try to find something that treats both. If that is not possible it is sometimes reasonable to treat one and see if the whole thing doesn't clear up (often it will) then treat the other if it does not rather than "shot gunning" with several different antibiotics at once. Signature00doc Hey 00doc... are you a doc... I can't read your handwriting? : ) Always, ..? ???)) -:?:- ?.?? .????)) ((??.?? ..?? cloud -:?:- -:?:- ((??.??* > The MRSA could be developing resistance to the Bactrim as well. Bactrim > (and several other older antibiotics) often work in MRSA. If they know > that the Staph aureus (SA) is resistant to methicillin (and so all > penicillins) (MR - MR+SA = MRSA) then they must have complete > susceptibilty testing and should be able to see what to use. <snipped for brevity> > Hello all I have an update ....seems no pcp evidence yet if ever I > dont know....doc( lung guy) looked at the xray and ct scan and [quoted text clipped - 19 lines] > working as well or quickly not sure why ,,Any ideas????? WOW how > things change in less than 3 weeks....Mahalo Michael Hi Michael: Sorry to hear that you do not have it pinned down yet. My sister in law is in much the same state: After a few days at home she started yet another 'round' with severe spasms and was taken back to the hospital by ambulance. Her MRSA seems to have been controlled by zyvox. But mycobacterium avium seems to have showed up, and is being treated with clarithromycin. Her asthma/emphysema is not responding as it should to a fairly heavy systemic dose of prednisone. This is causing her severe leg pains. Naturally the lung guy wants the dose maintained, while the infectious disease guy would prefer it reduced. The possibility of lung reduction surgery has been raised, but now I understand that she may be under consideration for a transplant. In case it is of interest, I came across this recently. Is cineol being used clinically yet 00Doc? MikeV Posted on Thursday, April 14, 2005 - 04:55 pm: -------------------------------------------------------------------------------- Subject: Cineol Respir Med. 2003 Mar;97(3):250-6. Anti-inflammatory activity of 1.8-cineol (eucalyptol) in bronchial asthma: a double-blind placebo-controlled trial. Juergens UR, Dethlefsen U, Steinkamp G, Gillissen A, Repges R, Vetter H. Department of Pneumology, Medical Outpatient Clinic, Bonn University Hospital, Germany. uwejuerg...t-online.de Airway hypersecretion is mediated by increased release of inflammatory mediators and can be improved by inhibition of mediator production. We have recently reported that 1.8-cineol (eucalyptol) which is known as the major monoterpene of eucalyptus oil suppressed arachidonic acid metabolism and cytokine production in human monocytes. Therefore, the aim of this study was to evaluate the anti-inflammatory efficacy of 1.8-cineol by determining its prednisolone equivalent potency in patients with severe asthma. Thirty-two patients with steroid-dependent bronchial asthma were enrolled in a double-blind, placebo-controlled trial. After determining the effective oral steroid dosage during a 2 month run-in phase, subjects were randomly allocated to receive either 200 mg 1.8-cineol t. i.d. or placebo in small gut soluble capsules for 12 weeks. Oral glucocorticosteroids were reduced by 2.5 mg increments every 3 weeks. The primary end point of this investigation was to establish the oral glucocorticosteroid-sparing capacity of 1.8-cineol in severe asthma. Reductions in daily prednisolone dosage of 36% with active treatment (range 2.5-10 mg, mean: 3.75 mg) vs. a decrease of only 7% (2.5-5 mg, mean: 0.91 mg) in the placebo group (P = 0.006) were tolerated. Twelve of 16 cineol vs. four out of 16 placebo patients achieved a reduction of oral steroids (P = 0.012). Long-term systemic therapy with 1.8-cineol has asignificant steroid-saving effect in steroid-depending asthma. This is the first evidence suggesting an anti-inflammatory activity of the monoterpene 1.8-cineol in asthma and a new rational for its use as mucolytic agent in upper and lower airway diseases. Regards, Richard Friedel monoterpene 1.8-cineol in asthma and a new rational for its use as > mucolytic agent in upper and lower airway diseases. Regards, > Richard > Friedel I just realized that I had read the Cineol reference earlier on this group. Posted by Richard Friedel. Lack of accreditation unintentional. M Hello mike....The latest for me is slowly getting better...I quit the lung doc after a long talk with my P.C. doc who referred me to the ID doc....... I now have an IV (cefotan) at home along with 3 other antibiotics in pill form .....the Iv is for 4 weeks and shall have lab tests prior to ending IV .....but am feeling much better now......I was according to new doc on a dosage way too low for my size along with trying only 1 drug at a time kept me bouncing between low grade infection of one while the other flaired........hope your sister in law finds her answer for me it took changing docs ..so I'm hopeful this may finally clear up......Mahalo Michael >> Hello all I have an update ....seems no pcp evidence yet if ever I dont >> know....doc( lung guy) looked at the xray and ct scan and says its not [quoted text clipped - 76 lines] > mucolytic agent in upper and lower airway diseases. Regards, Richard > Friedel I have struggled with a sinus infection that started 4 years ago after about 1 year my lungs became infected ..this started a roller coaster health ride for me ...many antibiotics , inhalers, and way too much predisone ,,,pred use was almost constant the last 3 years ...anyway seems alot of you here have similar troubles. I found the following on the web the interesting thing is long term prednisone use depresses the immune system leading to opertunistic infections the biggie is PCP. I talked my Dr. into a rx for bactrim ...what a drastic change for the better..lungs are clear and sinus is the best its been for 3 years.. I'm still taking bactrim so I am hoping the sinus also totally clears we'll see....so here is some food for thought. ....Michael The above is my original post .....the connection for me between asthma/prednisone/pcp is I was diagnosed by 5 different (prior) doctors with asthma , it seems when infected with pcp the toxins given off caused me to weeze so the 1st. doctor says asthma and with that diagnosis in place all the other doctors agreed and treated me for the wrong thing .....until my new doctor agreed to try bactrim. some studies indicate 30mg of prednisone daily for 2 months is all the long term necessary for some people... My original post was an alert for some other people that might be mis-diagnoised as I was . and a suggestion for them to follow this info up with their doctor... You can dive into bactrim prophylaxis and perhaps bring us all more up to date, however thats not my purpose...I know bactrim has been available for a long time and there a generic versions (cheap) Are you a doctor????? Mahalo Michael >> I'll direct you to the study from 2004 when I find it again,,but the >> case studies below take us down the path......PCP and [quoted text clipped - 127 lines] > > Nothing you have posted remotely supports the use you are touting here. Michael: Thank you for your post. I am interested in your subject for a family member who current has a staph pneumonia under similar circumstances. She is non-HIV, and is currently receiving gamma globulin, vancomycin, prednisone. Hope the following site will be of interest. Both HIV and non-HIV cases of PCP are referenced. http://www.medadvocates.org/diseases/opportunistic/pcp/main.html I hope to hear more about your continued success. MikeV >I have struggled with a sinus infection that started 4 years ago >after about [quoted text clipped - 107 lines] > a.. Hypogammaglobulinemia > a.. Patients with severe malnutrition thanks mikev for the link and the new site I can search.....I believe most doctors are good people and try their best to improve our health ...however today seems they are very busy almost to the point of overload .....so keeping up to date comes slowly...the web and info available to us allows us to ask informed questions of our doctors which sometimes reminds them of an old antibiotic or a new therapy...My( new) doctor doesn't mind this approach and I feel involved and sometimes helpful........Mahalo Michael > Michael: > [quoted text clipped - 105 lines] >> a.. Hypogammaglobulinemia >> a.. Patients with severe malnutrition > I have struggled with a sinus infection that started 4 years ago after about > 1 year my lungs became infected ..this started a roller coaster health ride [quoted text clipped - 73 lines] > a.. Hypogammaglobulinemia > a.. Patients with severe malnutrition Michael - Different things affect different people. I have been on prednisone since 1998. I have had daily doses that ranged from 80mgs a day to where I am now, 5mg. In that time I have had pneumonia once, and I think it ended up being pneumonia because I didn't listen to the doc and go to the hospital when she told me to (It was Christmas). I don't find myself more prone to infections then I was before, really. I tend to catch colds more easily, and if someone is sick around me, most likely I'll get it, but I don't get long term infections like the kind you are speaking of. Hope this helps. Life is uncertain - Eat dessert first! Nancy 8=: ) Hello nancy...I'm glad you don't have to deal with long term infections , like you said Different things affect different people ...My original post was an alert for some people that might be mis-diagnoised with asthma as I was . and a suggestion for them to follow up with their doctor the info presented ....long term prednisone use depresses the immune system that is what opens the door for pcp infection ...your right it dosent happen to everyone.....mahalo Michael >> I have struggled with a sinus infection that started 4 years ago after >> about [quoted text clipped - 107 lines] > Nancy > 8=: ) |
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2008 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.