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Transmission of multi-drug resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis buy triamterene 75 mg on line. Transmission of drug-resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in urban hospital: epidemiologic and restriction fragment length polymorphism analysis order triamterene 75mg on-line. Private pharmacies in tuberculosis control- a neglected link International Journal of Tuberculosis and Lung Disease buy cheap triamterene 75mg online, 2002 75mg triamterene otc, 6(2):171-173. Survey of knowledge, attitudes and practices for tuberculosis among general practitioners in Delhi, India. Use of thiacetazone, thiophen-2-carboxylic acid hydrazide and triphenyltetrazolium chloride. Advances in techniques of testing mycobacterial drug sensitivity, and the use of sensitivity tests in tuberculosis control programmes. Human Development Report 2003: Millennium Development Goals: A compact among nations to end human poverty. A comparison of three molecular assays for rapid detection of rifampin resistance in Mycobacterium tuberculosis. Evaluation of a commercial probe assay for detection of rifampin resistance in Mycobacterium tuberculosis directly from respiratory and non respiratory clinical specimens. European Journal of Clinical Microbiology and Infectious Diseases, 1998, 17:189-192. Detection of rifampicin resistance in Mycobacterium tuberculosis isolates from diverse countries by a commercial line probe assay as an initial indicator of multidrug resistance. Rifampin- and multidrug-resistant tuberculosis in Russian civilians and prison inmates: dominance of the beijing strain family. Low levels of drug resistance amidst rapidly increasing tuberculosis and human immunodeficiency virus: co-epidemics in Botswana. Epidemiological analysis of tuberculosis treatment outcome as a tool for changing tuberculosis control policy in Israel. Drug- resistant pulmnonary tuberculosis in Israel, a society of immigrants: 1985-1994. Screening and management of tuberculosis in immigrants: the challenge beyond professional competence. The new National Tuberculosis Control Programme in Israel, a country of high immigration. Drug-resistant tuberculosis in Poland in 2000: second national survey and comparison with the 1997 survey. Drug resistance among failure and relapse cases of tuberculosis: is the standard re-treatment regimen adequate? P was established 1948 early Notification all cases (rate) /100,000 Year of Rifampicin introduction 1970s early Estimated incidence (all cases) 5. P was established 1963 Notification all cases (rate) 10 /100,000 Year of Rifampicin introduction 1982 Estimated incidence (all cases) 10. P was established 1973 Notification all cases (rate) 47 /100,000 Year of Rifampicin introduction 1983 Estimated incidence (all cases) /100,000 Year of Isoniazid introduction 1973 Notification new sputum smear + 4439 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 34. P was established 1989 Notification all cases (rate) 16 /100,000 Year of Rifampicin introduction 1980 Estimated incidence (all cases) 29 /100,000 Year of Isoniazid introduction 1970s Notification new sputum smear + 4889 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 7. P was established 1950 Notification all cases (rate) 72 /100,000 Year of Rifampicin introduction 1985 Estimated incidence (all cases) >80 /100,000 Year of Isoniazid introduction 1970 Notification new sputum smear + 2802 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 45. P was established 1962 Notification all cases (rate) 120 /100,000 Year of Rifampicin introduction 1969 Estimated incidence (all cases) 190. P was established 1998 Notification all cases (rate) /100,000 Year of Rifampicin introduction 1972 Estimated incidence (all cases) 74. P was established 1989 Notification all cases (rate) 125 /100,000 Year of Rifampicin introduction 1990 Estimated incidence (all cases) 201 /100,000 Year of Isoniazid introduction 1965 Notification new sputum smear + 13683 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 58 /100,000 % Use of Short Course Chemotherapy Yes % Treatment Success 86 % Use of Directly Observed Therapy Yes 70. P was established 1963 Notification all cases (rate) 28 /100,000 Year of Rifampicin introduction 1970 Estimated incidence (all cases) 28. P was established 1931 Notification all cases (rate) 3 /100,000 Year of Rifampicin introduction 1971 Estimated incidence (all cases) 3. P was established 1920 Notification all cases (rate) 93 /100,000 Year of Rifampicin introduction 1972 Estimated incidence (all cases) /100,000 Year of Isoniazid introduction 1950s Notification new sputum smear + 380 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 40. P was established 1957 Notification all cases (rate) /100,000 Year of Rifampicin introduction 1970s Estimated incidence (all cases) 44. P was established (revised programme) Notification all cases (rate) 251 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 827 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 12393 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 135 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 58. P was established (revised programme) Notification all cases (rate) 400 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 875 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 15346 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 219 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 60. P was established (revised programme) Notification all cases (rate) 188 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 578 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 4296 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 138 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 67. P was established (revised programme) Notification all cases (rate) 423 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 530 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 6455 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 228 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 69. P was established (revised programme) Notification all cases (rate) 632 /100,000 Year of Rifampicin introduction 1979 Estimated incidence (all cases) 932 /100,000 Year of Isoniazid introduction 1968 Notification new sputum smear + 15264 Use of Standardized Regimens Yes Notification new sputum smear + (rate) 359 /100,000 % Use of Short Course Chemotherapy Yes 100 % Treatment Success 70. P was established 1953 Notification all cases (rate) 6 /100,000 Year of Rifampicin introduction 1971 Estimated incidence (all cases) 5. Surveillance of resistance to anti-tuberculosis drugs is an essential component of a monitoring system. The benefits of surveillance are multiple: strengthening of laboratory networks, evaluation of programme performance, and the collection of data that inform appropriate therapeutic strategies. Most importantly, global surveillance identifies areas of high resistance and draws the attention of national health authorities to the need to reduce the individual or collective shortcomings that have created them. Prevalence of resistance among previously untreated patients reflects programme performance over a long period of time (the previous 10 years), and indicates the level of transmission within the community. The prevalence of bacterial resistance among patients with a history of previous treatment has received less attention because surveillance of this population is a more complex process. Re-treatment patients are a heterogeneous group composed of chronic patients, those who have failed a course of treatment, those who have relapsed, and those who have returned after defaulting. In some settings, this population constitutes more than 40% of smear-positive cases. The association between drug resistance and re- treatment has been repeatedly demonstrated, both at the individual and the programme level; however, the prevalence of drug resistance varies greatly among subgroups of this population. This report therefore recommends that all subgroups of re-treatment cases be separately notified and their outcomes reported, and that surveillance of resistance be conducted on a representative sample of this population. This will make the comparison of resistance prevalence within and between countries more robust and will elucidate patterns of resistance among the subgroups, which will allow better definition of appropriate re- treatment strategies. It is now critical that we recognize the importance of the laboratory in the control of tuberculosis. The two previous reports were published in 1997 and 2001 and included data from 35 and 58 settings,a respectively. The goal of this third report is to expand knowledge of the prevalent patterns of resistance globally and explore trends in resistance over time. It includes 39 settings not previously included in the Global Project and reports trends for 46 settings.

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Physiologic dead space is volume of lungs that does not participate in gas exchange (wasted ventilation) Physiologic dead space includes the anatomic dead space plus a functional dead space in the alveoli triamterene 75 mg on-line, (i cheap 75 mg triamterene amex. The functional dead space can be thought of as the alveoli that do not participate in gas exchange triamterene 75mg without a prescription. The most important reason that the alveoli do not participate in gas exchange is an imbalance or 235 inequality of ventilation and perfusion in which ventilated alveoli are not perfuse by capillary blood buy discount triamterene 75mg. In normal person, physiologic dead space is nearly equal to the anatomic dead space where alveolar ventilation and blood flow are well matched. If physiologic dead space is greater, there is imbalance of ventilation and perfusion. When diaphragm contracts, abdominal contents are pushed downward and the ribs are lifted upward and outward. Compliance of lung and chest wall are inversely correlated with their elastic properties (elastance) Changes in lung compliance: Increase in lung compliance may occur due to loss of elastic fibers (e. Surfactant is lacking in premature infants, causing neonatal respiratory distress syndrome. Intrapleural and alveolar pressure are given in reference to atmospheric pressure Rest. Intrapleural pressure is negative (~ -5cmH2O) because opposing forces of lungs trying to collapse and chest wall trying to expand creates negative pressure in intrapleural space. The expanding force on the 238 lungs and airways at rest is + 5cmH2O (alveolar or airway pressure minus intraplural pressure) Inspiration. The reason is as lung volume increases, elastic recoil strength of lungs increases. The two effects together cause intrapleural pressure to be more negative (~ -8cmH2O). Alveolar pressure becomes positive (higher than atmospheric) because the elastic forces of the lung compress air in the alveoli. Following expiration, volume in the lung decreases and intrapleural pressure returns to its resting volume (i. Refers to energy expended to: • Expand elastic tissues of chest wall and lungs (compliance work) • Overcome viscosity of inelastic structures of chest wall and lungs (tissue resistance work). Alveolar gas exchange Gas exchange in the respiratory system refers to diffusion of oxygen and carbon dioxide in the lungs and in the peripheral tissues. Oxygen is transferred from alveolar gas into pulmonary capillary blood and, ultimately it is delivered to the tissues, where it diffuses from systemic capillary blood into the cells. Carbon dioxide is delivered from the tissues 239 to venous blood, (to pulmonary capillary blood), and is transferred to alveolar gas to be expired. Dalton’s law of partial pressure states that each gas contributes to the total pressure in direct proportion to its relative concentration. Henry’s law states that the actual concentration of dissolved gas in a liquid is equal to the partial pressure of the gas in contact with the liquid multiplied by the solubility coefficient of the gas in that particular liquid. Rate of transfer by diffusion is directly proportional to driving force, diffusion coefficient and surface area available for diffusion, but inversely proportional to thickness of membrane barrier. Total gas concentration in solution = dissolved gas + bound gas + modified gas Dissolved gas: For a given partial pressure, the higher the solubility of gas the higher the concentration in solution. PaO2 (practical pressure of O2 is arterial system) is slightly less than 100 mmHg because of physiological shunt. Physiologic shunt refers to the fraction of pulmonary blood flow that bypasses the alveoli, therefore is not arterialized. If shunt is small, then A-a is small (normal), If abnormal, A-a difference increases. Exactly opposite events occur in the pulmonary capillaries 246 Oxygen transport in the blood: O2 is carried in the blood in two forms. Each subunit contains heme moiety which is iron-binding porphyrin and polypeptide chain (either α or β). Adult Hb (HbA) has α2 β2 (2 of subunits have α chain and 2 have β chain) Each subunit can bind one molecule of O2, a total of 4 molecules of O2 for 1 molecule of Hb. For Hb subunits to bind O2, the iron in heme moieties must 2+) be in ferrous state (Fe Variants of Hb molecule: 3+ Methemoglobin- This is when iron molecule is in ferric (Fe ) state thus doesn’t bind O2. This is a Congenital variant Fetal Hb (HbF): In fetal Hb, the two β chains are replaced by ϒ chains (ϒ2 α2) HbF has higher affinity for O2 than HbA, facilitating O2 movement from mother to fetus. This Hb is replaced with HbA within the first year of life HbS: This is abnormal Hb, where α is normal, but β is abnormal. O2-Hb dissociation curve: Each molecule of Hb binds to 4 molecules of O2, which is 100% saturation. If 3 molecules of O2 bind - 75% saturation If 2 “ “ “ “ - 50% “ if 1 “ “ “ “ - 25% “ 248 Figure 67. Binding first molecule of O2 to a heme group increases the affinity for the second O2 molecule, the second to the third. The graph shown in figure 68 corresponds to 100% saturation and (affinity of Hg for O2 highest). Due to positive coaperativity, affinity of Hb for O2 is the highest, which corresponds to flat portion of curve (figure 68). Changes in the O2-Hb dissociation curve: Shift to the right: Occur when there is decreased affinity of Hb for O2 (see figure. Increases in temperature also cause right shift, and facilitate unloading of oxygen in the tissues. This decrease in affinity causes right shift and facilitates unloading of oxygen in the tissues. This facilitates O2 delivery to the tissues as adaptive mechanism 252 Figure 69 A. By the time blood reaches the venous end of the capillaries Hb is conveniently in its deoxygenated form (i. There is a useful + reciprocal relationship between the buffering of H by deoxyhemoglobin and the Bohr + effect. Thus the H generated from the tissue Co2 causes hemoglobin to release O2 + more readily to the tissues. The frequency of normal, involuntary breathing is controlled by three groups of neurons or brainstem centers. Afferent (sensory) information reaches the medullary inspiratory center Via central and peripheral chemoreceptors and via 259 mechanoreceptor. Efferent (motor) information is sent from inspiratory center to the phrenic nerve, which innervates the diaphram. Inspiration is shortened by inhibition of inspiratory center via the pneumotaxic center (see below) • Expiratory center (see figure 68) is located in the ventral respiratory neurons and is responsible primarily for expiration. Since expiration is normally a passive process, these neurons are inactive during quite breathing. However, during exercise when expiration becomes active, this center is activated • Apneustic Center. Apneusis is an abnormal breathing pattern with prolonged inspiratory gasps, followed by brief expiratory movement. Stimulation of apneustic center in the lower pons excites the inspiratory center in the medulla, prolonging the contraction of the phrenic nerve.

Vascular or Lymphatic Invasion Describes whether the cancerous cells have infiltrated the vascular/lymphatic system supplying the breast 75mg triamterene otc. Ploidy Diploid cancers cells have the same amount of chromosomes as normal cells and tend to be slower growing buy triamterene 75 mg otc, less aggressive cells buy cheap triamterene 75mg line. Aneuploid cancer cells have too many/too little amount of chromosomes and tend to be rapid growing aggressive cells purchase triamterene 75 mg. Hormone Receptor Status Hormone receptor status determines if hormone therapy would be appropriate. Tumour is < 5 cms across, and has spread to underarm lymph nodes that T0 N2 M0 are attached to each other or nearby tissue. Or may have spread to lymph nodes behind the breastbone but T3 N2 M0 not spread to underarm lymph nodes. Tumour can be any size and has grown into the chest wall or the skin of T4 N0 M0 the breast. T = Status of primary tumour, N = Regional lymph nodes, M = Distant metastases (Singletory and Connelly, 2006) 23 Psychological impact of a breast cancer diagnosis The obtaining of a cancer diagnosis is a very emotional time for a woman, the following are common reactions:  Shock and blame  Sadness  Fear, anxiety and panic  Uncertainty and loneliness  Anger and resentment  Fatigue  Depression and denial  Vulnerability Expressive coping and actively processing emotions is of benefit to patients at the time of diagnosis. It leads to lower medical appointments due to cancer related morbidities plus a higher quality of life (Stanton et al, 2002). However the expression of fear and anxiety is associated with lower quality of life and higher depression (Lieberman and Goldstein 2006). The New Zealand cancer foundation provides a variety of methods for dealing with such a stressful time in a person’s life: http://www. Due to the rarity of this condition, it is often over looked and when found, is at an advanced stage. Signs and symptoms, diagnosis and treatment options are all the same as those previously described. After lumpectomy, all the tissue removed from the breast is examined carefully to see if cancer cells are present in the margins. If cancer cells are found in the margins, additional surgery (re-excision) will be performed to remove the remaining cancer. Sometimes both breasts are removed (a double mastectomy), often as preventive surgery in women at very high risk for breast cancer. Modified Radical Mastectomy Involves the removal breast tissue and axillary lymph nodes (B and C in illustration). Less extensive surgery (such as modified radical mastectomy) has been found to be just as effective and so radial mastectomies are now rarely performed. However, this operation may still be done for large tumours that are growing into the pectoral muscles under the breast. Subcutaneous (“Nipple Sparing”) Mastectomy All of the breast tissue is removed, but the nipple is left alone. Skin Sparing Mastectomy Technique that preserves as much of the breast skin as possible during simple, total, or modified radical mastectomy to provide the skin needed for immediate reconstruction. Only the skin of the nipple, areola, and the original biopsy scar are removed to create a small opening for removal of the breast tissue. Usually done at the same time as the mastectomy or lumpectomy, but can also be performed after through a separate incision. This procedure is a way of learning if cancer has spread to lymph nodes without removing as many of them. In this procedure the first lymph node to which a tumour is likely to drain is removed (known as the sentinel node). Infection of the mastectomy wound may progress to late postoperative lymphoedema of the arm (Morrow et al, 2009). Risk factors include; open biopsy before mastectomy, obesity, diabetes, increase in age and prolonged suction catheter drainage (Vitug and Newman, 2007). After mastectomy, seromas occurs in the dead space beneath the elevated skin flap in approximately 30% of cases (Hashemi et al, 2004). Recent research recommends that in the presence of a seroma, arm mobility should be allowed immediately after surgery but structured physiotherapy exercise should be delayed until at least one week post-operatively (Shamley et al, 2005, Shcutz et al, 1997). The patient usually experiences moderate pain in the shoulder and arm in the immediate postoperative period (Kroner et al, 1992). The patient may note hyperesthesia and paraesthesia, as well as occasional "phantom" hyperesthesia in the mastectomy site (Stubblefield and Custodio 2006). It presents as a non-painful phantom sensation such as itching, nipple sensation, and premenstrual-type breast discomfort. There is currently a lack of high quality literature around the physiotherapy management of phantom breast syndrome however treatment generally involves education and analgesics (Stubblefield and Custodio 2006). Physiotherapists will also be part of an ongoing multidisciplinary pain management programme. Manual techniques such as myofascial release have also been considered useful in improving tissue extensibility and enhancing mobility. After discharge:  Patients should be advised to use their limb as normally as possible  The unaffected limb should be used for heavier or repetitive tasks e. Todd et al (2008): conducted a randomised single-blind control trial of 116 women undergoing surgery that included axillary node dissection for early breast cancer. The intervention group completed an alternative programme limiting movements to less than 90 degrees in all planes for the first week postoperatively before progressing to the standard protocol. There were no significant differences between groups for other musculoskeletal morbidities, however abduction limitation was -11. We see only ones backward shoulder rolls to decrease referred to us from surgical, apprehension and pain, improve medical, and radiation postoperative pulmonary function, and oncologists, nurse prepare the patient for progression. Distal upper extremity exercises are Once drain(s) are removed, Skin stretching and 32 included but not stressed. One cycle entails a treatment period (could be one day, a few days in a row or every other day for a set period) followed by a recovery period during which no treatment is given. The number of cycles in a regimen and the duration of each regimen varies depending on the drugs used, but most take 3-6 months to complete. Symptoms include:  Numbness  Tenderness  Tingling, burning,  Rash  Redness  Cracked, flaking, or peeling skin  Swelling  Blisters, ulcers, or sores  Discomfort  Intense pain 34  Difficulty walking or using your hands Patients should be advised not to exercise with this condition so therefore physiotherapist must liaise with doctor before starting an intervention. Supervised group exercise significantly reduces depression and anxiety levels in a wide range of cancer patients undergoing chemotherapy (Midtgaard et al, 2005). Sexuality Breast surgery as well as chemotherapy, can induce a change in “body image, femininity, power of seduction and sexuality”, which can adversely affect the patient’s relationship with their partner (Hannoun-Levi 2005). External radiotherapy: delivered by a machine, most commonly a linear accelerator. Internal radiotherapy: a radioactive pellet is placed inside the body, close to the tumour, for a set amount of time. Indications/Uses 1) Adjuvant (after surgery): Lumpectomy followed by whole breast radiation is often referred to as “breast preservation surgery” and is very common.

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