Tuberculosis suspect. Productive cough for more than 2 weeks, which may be accompanied by other respiratory symptoms and/or constitutional symptoms
Case of tuberculosis. A definite case of TB or one in which a health worker (clinician or other medical practitioner) has diagnosed TB and has decided to treat the patient with a full course of TB treatment.
Any person given treatment for TB should be recorded as a case. Incomplete “trial” TB treatment should not be given as a method for diagnosis.
RNTCP guidelines for tuberculosis management: Extended versionRxVichuZ
This presentation is an extension of the already made presentation before, that deals with RNTCP guidelines for some special aspects encountered during tuberculosis management, other than management of individual diagnoses alone.
Have a look!
The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment and person-to-person transmission. Most people with TB are cured by a strictly followed, 6-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective formulations of drugs (such as use of single drugs, poor quality medicines or bad storage conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted, especially in crowded settings such as prisons and hospitals.
In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many adverse effects from the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 117 countries worldwide.
Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs or detect resistance patterns. These tests can be molecular in type (such as Xpert MTB/RIF) or else culture-based. Molecular techniques can provide results within hours and have been successfully implemented even in low resource settings.
New WHO recommendations aim to speed up detection and improve treatment outcomes for MDR-TB through use of a novel rapid diagnostic test and a shorter, cheaper treatment regimen. At less than US$ 1000 per patient, the new treatment regimen can be completed in 9–12 months. Not only is it less expensive than current regimens, but it is also expected to improve outcomes and potentially decrease deaths due to better adherence to treatment and reduced loss to follow-up.
Solutions to control drug-resistant TB are to:
cure the TB patient the first time around
provide access to diagnosis
ensure adequate infection control in facilities where patients are treated
ensure the appropriate use of recommended second-line drugs.
In 2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000 people with rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India, China, and the Russian Federation accounted for 45% of the 580 000 cases. It is estimated that about 9.5% of these cases were XDR-TB.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
RNTCP guidelines for tuberculosis management: Extended versionRxVichuZ
This presentation is an extension of the already made presentation before, that deals with RNTCP guidelines for some special aspects encountered during tuberculosis management, other than management of individual diagnoses alone.
Have a look!
The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment and person-to-person transmission. Most people with TB are cured by a strictly followed, 6-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective formulations of drugs (such as use of single drugs, poor quality medicines or bad storage conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted, especially in crowded settings such as prisons and hospitals.
In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many adverse effects from the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 117 countries worldwide.
Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs or detect resistance patterns. These tests can be molecular in type (such as Xpert MTB/RIF) or else culture-based. Molecular techniques can provide results within hours and have been successfully implemented even in low resource settings.
New WHO recommendations aim to speed up detection and improve treatment outcomes for MDR-TB through use of a novel rapid diagnostic test and a shorter, cheaper treatment regimen. At less than US$ 1000 per patient, the new treatment regimen can be completed in 9–12 months. Not only is it less expensive than current regimens, but it is also expected to improve outcomes and potentially decrease deaths due to better adherence to treatment and reduced loss to follow-up.
Solutions to control drug-resistant TB are to:
cure the TB patient the first time around
provide access to diagnosis
ensure adequate infection control in facilities where patients are treated
ensure the appropriate use of recommended second-line drugs.
In 2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000 people with rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India, China, and the Russian Federation accounted for 45% of the 580 000 cases. It is estimated that about 9.5% of these cases were XDR-TB.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
This presentation is about lab diagnosis of tuberculosis. It highlights use of currently available diagnostic methods in identifying pulmonary and extrapulmonary tuberculosis.
Optimising haemodynamics in septicaemia / HOCF saves lives! Optimising haemodynamics early saves even more lives!
Associate Professor Brendan E. Smith.
School of Biomedical Science, Charles Sturt University,
Specialist in Anaesthesia and Intensive Care, Bathurst Base Hospital, Bathurst, NSW, Australia.
This presentation is about lab diagnosis of tuberculosis. It highlights use of currently available diagnostic methods in identifying pulmonary and extrapulmonary tuberculosis.
Optimising haemodynamics in septicaemia / HOCF saves lives! Optimising haemodynamics early saves even more lives!
Associate Professor Brendan E. Smith.
School of Biomedical Science, Charles Sturt University,
Specialist in Anaesthesia and Intensive Care, Bathurst Base Hospital, Bathurst, NSW, Australia.
While the world was focused on covid 19, WHO has made and issued consolidated guidelines making changes in how to prevent, diagnose and treat tuberculosis.
Vasculitis syndrome an approach -and-basic principles of treatmentSachin Verma
Vasculitides are a hetrogenous group of conditions characterized by inflammation and necrosis of blood vessels.
A broad group of syndromes may result from this process,since any type,size, and location of vessel may be involved.
Type 2 dm gdm new updates & guidelinesSachin Verma
Type 2 diabetes is a multifactorial disorder characterised by progressive pancreatic beta-cell dysfunction and insulin- resistance, leading to relative insulin deficiency, chronic hyperglycaemia, and various complications.
The treatment options for this disorder, which aim at correcting one or other of the two major pathophysiological mechanisms, have been hamstrung by unacceptable side-effects, lack of patient acceptability, and loss of efficacy over time.
Proteinuria – early indicator of renal disease
Increases the risk of renal impairment, hypertension & cardiovascular disease.
Proteinuria of 1+ or more persisting on 2 subsequent dipstick tests at weekly intervals – requires further investigations.
Causes of transient proteinuria to be excluded
Vertigo –the dizzy patient an evidence-based diagnosis and treatment strategySachin Verma
Vertigo is a symptom of illusory movement and not a diagnosis .It is due to asymmetry of vestibular system due to damage or dysfunction of the
Labyrinth and vestibular nerve, or
Central vestibular structures in the brainstem
Urine examination how to approach final.ppt1Sachin Verma
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Surat @ℂall @Girls ꧁❤8527049040❤꧂@ℂall @Girls Service Vip Top Model Safe
Tuberculosis update
1. UPDATE IN
TUBERCULOSIS
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Ivy Hospital Sector 71 Mohali
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495
Page 1
3. Outline
• Why a fourth edition
• New recommendations
• Integrating MDR prevention, diagnosis,
and treatment into the National TB
Program (NTP).
3 Page 3
4. Universal access to quality TB care
for all TB patients
•No longer assign lower priority to patients
with smear negative or MDR disease
(formerly Category 3, 4)
•Detection and treatment of MDR-TB should
be an integral part of NTP activities
4 Page 4
5. Prior WHO guidelines
• Not evidence-based
• Too much dependence on expert
opinion
• Decisions not transparent
Oxman, Lancet 2007; 369
5 Page 5
6. New WHO requirements for guidelines:
formulate questions
• Duration of rifampicin in new patients
• Dosing frequency in new patients
• TB treatment in people living with HIV
• Sputum monitoring and treatment extension
• Regimen for new TB patients in countries with
high levels of isoniazid resistance
• Use of the 8 month retreatment regimen with first
line drugs (“Cat 2”)
6 Page 6
7. Strength of recommendations
• Strong (“should”): desirable effects clearly
outweigh undesirable
– High quality evidence, large certain benefit
• Conditional (“may”): trade offs are uncertain
– Evidence is lacking or low quality
– Benefits small or difficult to quantify, may not justify
cost
• Weak: insufficient evidence (based on field
application and expert opinion)
• Not rated: quality of evidence not assessed.
7 Page 7
8. Key changes since the third
edition
Instead of “Diagnostic categories I–IV”,
this edition uses the same patient
registration groups used for recording
and reporting, which differentiate new
patients from those with prior treatment
and specify reasons for retreatment.
Page 8
12. New guideline
1. New patient regimen : 2 HRZE/4HR Cat I
2. Retreatment regimen with first line
Cat II
drug : 2SHRZE/HRZE/5HRE
Page 12
13. New guideline
• Tuberculosis suspect. Productive cough for more than 2
weeks, which may be accompanied by other respiratory
symptoms and/or constitutional symptoms
• Case of tuberculosis. A definite case of TB or one in
which a health worker (clinician or other medical
practitioner) has diagnosed TB and has decided to treat the
patient with a full course of TB treatment.
• Any person given treatment for TB should be recorded as
a case. Incomplete “trial” TB treatment should not be given
as a method for diagnosis.
Page 13
14. New guideline
• The recent WHO case definition for sputum smear-positive
pulmonary TB has been applied to a definite case of TB.
• A patient with one positive AFB smear is considered a
definite case. (In the third edition, two positive smears were
required before a patient could be considered a definite
case.)
• There is reduction in the number of specimens from three
to two for screening patients suspected to have TB.
Page 14
15. Duration of rifampicin in new patients
Should new pulmonary TB patients be treated with the
6-month rifampicin regimen (2HRZE/4HR)
or
2-month rifampicin regimen (2HRZE/6HE)?
Page 15
16. Recommendation 1
New patients with pulmonary TB should receive a
regimen containing 6 months of rifampicin: 2HRZE/4HR
Also applies to extrapulmonary TB, except TB of the
central nervous system, bone or joint for which some expert
groups suggest longer therapy
(Strong/High grade of evidence)
Recommendation 2
The 2HRZE/6HE treatment regimen should
be phased out*
(Strong/High grade of evidence)
Page 16
17. Initial regimen in countries with high
levels of isoniazid resistance
Recommendation 1
2HRZE/4HRE
In populations with known or suspected
high levels of isoniazid resistance,
new TB patients may receive HRE as
therapy
in the continuation phase as an acceptable
alternative to HR
(Weak/Insufcient evidence, expert opinion)
Page 17
18. Why concern about Isoniazid
resistance in new patients?
• Outcomes are significantly worse than for patients with
isoniazid susceptible disease
– Risk of failure 11x higher, and relapse 2x higher
• It’s a stepping stone to MDR
– 5x higher risk of acquired drug resistance
• It’s common: Globally, 7% of new patients resistant to at
least isoniazid (but not yet to rifampin).
18 Page 18
19. Standard Regimens For New TB patients
In presumed, or known, to have drug-susceptible TB
who no longer recommends omission of ethambutol during the intensive
phase of treatment for patients with non-cavitary, smear-negative pTB or
epTB who are known to be HiV-negative. in tuberculous meningitis,
ethambutol should be replaced by streptomycin.
In settings where the level of isoniazid resistance among new TB cases
is high and isoniazid susceptibility testing is not done (or results are not
available) before the continuation phase begins)
Page 19
20. Dosing frequency in new patients
Recommendation 1
Wherever feasible, the optimal dosing frequency for new patients
with pulmonary TB is daily throughout the course of therapy
(Strong/High grade of evidence)
Recommendation 1.1
New patients with pulmonary TB may receive a daily intensive
phase followed by a three times weekly continuation phase
[2HRZE/4(HR)3]provided that each dose is directly observed
(Conditional/High and moderate grade of evidence)
Recommendation 1.2
Three times weekly dosing throughout therapy 2(HRZE)3/4(HR)3]
may be used as another alternative to Recommendation 1.1,
provided that every dose is directly observed and the patient is NOT
living with HIV or living in an HIV-prevalent setting
(Conditional/High and moderate grade of evidence)
Page 20
22. Recommendation 2
New patients with TB should not receive twice
weekly dosing for the full course of treatment unless
this is done in the context of formal research
(Strong/High grade of evidence)
Page 22
23. Tb treatment in persons living with HIV TB
patients living in HIV prevalent settings
Recommendation 1
TB patients with known positive HIV status and all TB patients living
in HIV prevalent settings should receive daily TB treatment at least
during the intensive phase
(Strong/High grade of evidence)
Remark
HIV-prevalent settings are defined as countries, subnational administrative units,
or selected facilities where the HIV prevalence among adult pregnant women is
≥1% or among TB patients is ≥5%
Page 23
24. Page 24
World health Organization Global Tuberculosis Control A short update to the 2009 report
25. Recommendation 2
For the continuation phase, the optimal dosing frequency is
also daily for these patients
(Strong/High grade of evidence)
Recommendation 3
If a daily continuation phase is not possible for these
patients, three times weekly dosing during the continuation phase is
an acceptable alternative
(Conditional/High and moderate grade of evidence)
Recommendation 4
It is recommended that TB patients who are living with HIV
should receive at least the same duration of TB treatment as HIV-
negative TB patients
(Strong/High grade of evidence)
Page 25
27. Treatment extension in new pulmonary
Tb patients
Recommendation 1
In patients treated with the regimen containing
rifampicin throughout treatment, if a positive sputum
smear is found at completion of the intensive phase, the
extension of the intensive phase is not recommended
(Strong/High grade of evidence)
Page 27
28. Smear status at the end of the intensive
phase
1. Poor predictor of which new patients will relapse.
2. However, detection of a positive sputum smear remains
important as a trigger for the patient assessment,
quality of patient’s support and supervision and
intervention promptly if necessary
3. Continue HR and sputum monitoring on month 3 if
specimen obtained at the end of month 3 is smear
positive sputum culture and drug susceptibility testing
should be performed
Page 28
29. A positive sputum smear at the end of the intensive
phase may indicate any of following
1. the initial phase of therapy was poorly supervised and
patient adherence was poor
2. poor quality of anti-TB drugs
3. doses of anti-TB drugs are below the recommended
range
4. resolution is slow because the patient had extensive
cavitation and a heavy initial bacillary load;
5. non-viable bacteria remain visible by microscopy.
Page 29
30. Sputum monitoring, new patients
Recommendations (Strong): if specimen obtained at
end of intensive phase is smear +, repeat at end of
third month. If still positive, obtain culture and DST
Failure: + bacteriology
at 5th month or later, or
MDR detected any time
30 Page 30
31. Previously treated patients
Recommendation 1
Specimens for culture and drug susceptibility testing (DST)
should be obtained from all previously treated TB patients at or
QUESTION of treatment. DST should be performed for at least
before the start 1
isoniazid and rifampicin
Recommendation 2
In settings where rapid molecular-based DST is available, the
results should guide the choice of regimen
Page 31
32. Recommendation 3
In settings where rapid molecular-based DST results are
not routinely available to guide the management of individual
patients, empirical treatment should be
started as follows:
Recommendation 3.1
TB patients whose treatment has failed or other patient
groups with high likelihood of multidrug-resistant TB
(MDR-TB) should be started on an empirical MDR regimen
Recommendation 3.2
TB patients returning after defaulting or relapsing from
their first treatment course may receive the retreatment
regimen containing first-line drugs 2HRZES/1HRZE/5HRE
if country-specific data show low or medium levels of MDR
in these patients or if such data are unavailable
Page 32
33. Recommendation 4
In settings where DST results are not yet routinely
available to guide the management of individual patients, the
empirical regimens will continue through out the course of
treatment
Page 33
34. Previously treated patients
Weighted mean of MDR-TB in new MDR in retreatment TB cases from drug
and retreatment TB cases from resistance surveysand surveillance in
drug resistance surveys, 1994–2007 10 countrieS, 1997–2007
Page 34
35. Type of Results Approach to retreatment
DST available
Rapid Hours to Use DST results to decide
days if MDR regimen needed
Conventional Days to Start empiric regimen while
weeks awaiting DST results.
Once DST results
available, may change
regimen.
None Not Use empiric regimen for
(Interim) available full course of treatment.
35 Page 35
36. MDR likelihood
(patient registration group)
Type of High Medium
DST (after failure) (relapse, default)
Rapid DST results guide choice of regimen
from the start
While awaiting DST results (empiric):
MDR regimen 2HRZES/HRZE/5HRE
Conventional
Modify on basis of DST results once
available
None Interim 36 Page 36
37. Country-specific drug resistance
data country-specific drug
NTPs should obtain and use their
resistance data on failure, relapse and default patient
groups to determine the levels of MDR (rec #7.5)
Need to verify or modify the assignment of:
• Failure patients to high likelihood of MDR
• Relapse and default patients to moderate likelihood of
MDR
37 Page 37
38. Sputum monitoring, previously treated
patients on first line drugs
Recommendation (Strong): if specimen obtained at
end of intensive phase is sm +, obtain culture, DST
38 Page 38
40. DEFINATIONS
• MDR (Multidrug resistant tuberculosis)
resisted to at least H, R
• XDR (Extensive drug resistant tuberuculosis)
strain of MDR-TB which also resisted to any one
member of fluoroquinolones and one of injected
anti-TB drugs : kanamycin, amikacin,
capreomycin
Page 40
49. management of cutaneous reactions
itching without a rash and there is no other obvious cause
symptomatic treatment with antihistamines and skin moisturizing,
and continue TB treatment while observing the patient closely
skin rash develop
all anti-TB drugs must be stopped. Once the reaction has
resolved, anti-TB drugs are reintroduced one by one,
starting with the drug least likely to be responsible for the
reaction (rifampicin or isoniazid) at a small challenge dose, such as
50 mg isoniazid
dose is gradually increased over 3 days. This procedure is
repeated, adding in one drug at a time. A reaction after adding in a
particular drug identifes that drug as the one responsible for the
reaction.
Page 49
WHO Treatment of tuberculosis guideline 2010
50. Management of antituberculosis induce hepatitis
Of the first-line anti-TB drugs, isoniazid, pyrazinamide and rifampicin
can all cause liver damage
The management of hepatitis induced by TB treatment depends on:
— whether the patient is in the intensive or continuation phase of
TB treatment;
— the severity of the liver disease;
— the severity of the TB
Page 50
51. All drugs should be stopped
If the patient is severely ill with TB and it is considered
unsafe to stop TB treatment, a non-hepatotoxic regimen
consisting of streptomycin, ethambutol and a
fuoroquinolone should be started.
If TB treatment has been stopped, it is necessary to wait
for liver function tests to revert to normal and clinical
symptoms (nausea, abdominal pain) to resolve before
reintroducing the anti-TB drugs.
Page 51
52. Once drug-induced hepatitis has resolved, the drugs are
reintroduced one at a time. If symptoms recur or liver
function tests become abnormal as the drugs are reintro-
duced, the last drug added should be stopped.
Some advise starting with rifampicin because it is less
likely than isoniazid or pyrazinamide to cause
hepatotoxicity and is the most efective agent After 3–7
days, isoniazid may be reintroduced.
In patients who have experienced jaundice but tolerate
the reintroduction of rifampicin and isoniazid, it is
advisable to avoid pyrazinamide.
Page 52
53. Alternative Regimen
If rifampicin cannot be used………………………2SHE/10HE)
regimen without rifampicin is 2 months of isoniazid, ethambutol
and streptomycin followed by 10 months of isoniazid and
ethambutol.
If isoniazid cannot be used………………………........(6-
9RZE)
6–9 months of rifampicin, pyrazinamide and ethambutol
If pyrazinamide cannot be used…………………..(2HRE/7HR)
before the patient has completed the intensive phase, the total
duration of isoniazid and rifampicin therapy may be extended to 9
months
If neither isoniazid nor rifampicin can be used….8-24 EOS)
the non-hepatotoxic regimen consisting of streptomycin,
ethambutol and a fuoroquinolone should be continued forPage 53 of
a total
55. Treatment of extrapulmonary Tb
Pulmonary and extrapulmonary disease should be treated with
the same regimens
some experts recommend 9–12 months of treatment for TB
meningitis and 9 months of treatment for TB of bones or joints
Unless drug resistance is suspected
adjuvant corticosteroid treatment is recommended for TB
meningitis and pericarditis
In tuberculous meningitis,ethambutol should be replaced by
streptomycin.
fourth edition no longer includes the option of omitting
ethambutol during the intensive phase of treatment(2HRZ/4HR)
for patients with extrapulmonary disease who are known to be
HIV-negative
Page 55
57. HIV
• Irrespective of epidemic setting, WHO recommends HIV
testing for patients of all ages who present with signs or
symptoms that suggest tuberculosis , whether TB is
suspected or already confirmed.
• The first priority for HIV-positive TB patients is to initiate
TB treatment, followed by co-trimoxazole and ART .
• ART should be initiated for all people living with HIV with
active TB disease irrespective of CD4 cell count.
• TB treatment should be started first, followed by ART as
soon as possible and within the first 8 weeks of starting
TB treatment
Page 57
58. • WHO recommends that the first-line ART regimen contain two
.
nucleoside reverse transcriptase inhibitors (NRTIs) plus one
non-nucleoside reverse transcriptase inhibitor (NNRTI).
• The recommended first-line ART regimens for TB patients are
those that contain efavirenz (EFV), since interactions with anti-
TB drugs are minimal.
• efavirenz should not be used in women of childbearing potential
without adequate contraception, nor should it be used for
women who are in the first trimester of pregnancy.
• WHO recommends that NTPs undertake DST at the start of TB
therapy in all HIV-positive TB patients, to avoid mortality due to
unrecognized drug-resistant TB .
Page 58
59. NACO GUIDELINE
TYPE OF TB CD4 COUNT INITIATION OF ART
PULMONARY < 350 BETWEEN 2 WEEKS
TO 2 MONTHS
ZDV(D4T)+3TC+EFV
EXTRAPULMONARY ALL HIV + BETWEEN 2 WEEKS
TO 2 MONTHS
ZDV(D4T)+3TC+EFV
Page 59
60. CDC GUIDELINE
For patients with a CD4+ count <100/cc, ART should be started
after >2 weeks of TB treatment to reduce confusion about
overlapping toxicities, drug interactions, and the occurrence of
paradoxical reactions or IRIS.
• For persons with a CD4+ count of 100–200/cc,delay ART until
the end of the 2-month intensive phase of anti-TB treatment.
• In those with a sustained CD4+ count 200-350/cc, ART could
be started during the anti-TB maintenance phase.
Page 60
61. renal failure and severe renal insuffciency
RIF and INH are metabolized by the liver, so
conventional dosing may be used in the setting of renal
insufficiency
PZA is also metabolized by the liver but its metabolites
may accumulate in patients with renal insufficiency
EMB is about 80% cleared by the kidneys and may
accumulate in patients with renal insufficiency
Page 61
MMWR 2003;52:63-64
62. Decrease dose or increasing the dosing interval ?
• Decreasing the dose of selected antituberculosis drugs
may not be the best method of treating tuberculosis
because,although toxicity may be avoided, the peak
serum concentrations may be too low.
• Therefore increasing the dosing interval of pyrazinamide
and ethambutol are recommended and doses should be
adjusted Three times per week
Page 62
MMWR 2003;52:63-64
64. pregnancy and breastfeeding
A pregnant woman
The first line anti-TB drugs are safe for use in pregnancy With the
exception of streptomycin, streptomycin is ototoxic to the fetus and
should not be used during pregnancy.
A breastfeeding woman
should receive a full course of TB treatment. Timely and properly
applied chemotherapy is the best way to prevent transmission to the
baby. After active TB in the baby is ruled out, the baby should be
given 6 months of isoniazid preventive therapy,
Pyridoxine supplementation is recommended for all pregnant or
breastfeeding women taking isoniazid
Page 64
65. LIVER DISEASE
If the serum alanine aminotransferase level is more than 3 times
normal before the initiation of treatment,1 of the following regimens
should be considered :
• Two hepatotoxic drugs (rather than the three in the standard
regimen):
— 9 HRE
— 2 HRSE followed by 6 HR
— 6–9 RZE
• One hepatotoxic drug:
— 2 HES followed by 10 HE
• No hepatotoxic drugs:
— 18–24 months of streptomycin, ethambutol and a fluoroquinolone.
Page 65