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By M. Raid. Dallas Baptist University.

One of the central concerns of epidemiology is to find and enumerate appropriate denominators in order to describe and compare groups in a meaningful and useful way buy trazodone 100 mg without a prescription symptoms in early pregnancy. It expresses the relationship between two numbers in the form of x: y or x/y X k Example: -The ratio of males to females (M:F) in Ethiopia trazodone 100 mg fast delivery symptoms ms women. It is a specific type of ratio in which the numerator is included in the denominator and the result is expressed as a percentage buy 100mg trazodone amex medicine vicodin. Example: The proportion of all births that was male Male births x 100 Male + Female births Rate Rate is the most important epidemiological tool used for measuring diseases cheap trazodone 100mg free shipping medications and grapefruit juice. It is 33 the measure that most clearly expresses probability or risk of disease in a defined population over a specified period of time, hence, it is considered to be a basic measure of disease occurrence. Accurate count of all events of interest that occur in a defined population during a specified period is essential for the calculation of rate. Rate = Number of events in a specific period x k Population at risk of these events in a specified Period Example: The number of newly diagnosed pneumonia cases in 1999 per 1000 under five children. Incidence rate The incidence of a disease is defined as the number of new cases of a disease that occur during a specified period of time in a population at risk for developing the disease. Incidence rate = Number of new cases of a disease over a period of time X K 34 Total Population during the given period of time The critical element in the definition of incidence is new cases of disease. The appropriate denominator for incidence rate is population at risk but knowing the population at risk is difficult at this level. For incidence to be a measure of risk we must specify a period of time and we must know that all of the individuals in the group represented by the denominator have been followed up for that entire period. The choice of time period is arbitrary: We could calculate incidence rate in one week, one month, one year, 5 years, and so on. If the incidence rate of a certain disease is high in one area, then the risk of acquiring that disease by other healthy individuals will be high. Answer- Incidence rate = 50 X 1000 = 10 new cases per 1000 population 5000 35 That means out of every 1000 people living in “Kebele X”, 10 of them acquired relapsing fever in Ginbot 1995. Attack rate = 90 X 100 = 90 cases of diarrhea per 100 people 100 That means out of 100 people who ate the food served by Ato Alemitegnaw, 90 of them developed diarrhea on Tir 8, 1995. Uses incidence rate Incidence rate is important as a fundamental tool for etiologic studies of diseases since it is a direct measure of risk. If the incidence rate is 36 significantly higher in one area, then the cause of that disease can be systematically searched. Prevalence rate Prevalence rate measures the number of people in a population who have a disease at a given time. Point Prevalence rate: measures the proportion of a population with a certain condition at a given point in time. Point Prevalence rate = All persons with a specific Condition at one point in time X K Total population Example: One health extension worker conducted a survey in one of the nearby elementary schools on Hidar 10, 1996 to know the prevalence of trachoma in that school. Point prevalence rate= 100 X 100 = 50 trachoma patients per 100 students 200 on Hidar10,1996 That means 50 % of the students in that elementary school were affected by trachoma on Hidar 10, 1996. Uses of prevalence rate Planning health facilities and human resource Monitoring chronic disease control programs like tuberculosis control program 6. Rates whose denominators are the total population are commonly calculated using either the mid - interval population or the average population. Population count at the beginning + Population count Average population = at the end of the time interval considered 2 38 Below are given some formulas for the commonly used mortality rates and ratios. Thus, it is high among people who have little health care, chiefly because infections, such as pneumonia, diarrhea and malaria, are common among their infants. Exercise: 43 The following information is about kebele X which was collected for the year 1999: – Total average population = 40,000 – Total number of live births = 4000 – Total number of deaths = 400 – Total number of deaths before the age of 28 days = 50 – Total number of infant deaths = 200 – Number of women who died from pregnancy related causes = 160 – New cases of tuberculosis = 100 – All cases of tuberculosis = 300 – Deaths from tuberculosis = 60 Based on the above information calculate the following. Sources of Data There are different sources of data on health and health related conditions in the community. The information obtained from these sources is used for health planning, programming and evaluation of health services. Census data are necessary for accurate description of population’s health status and are principal source of denominator for rates of disease & death. It provides information on: Size and composition of a population The trends anticipated in the future. Data was collected on: Age, sex and size of the population Mortality, fertility Language, ethnicity Housing From these data different health indices could be calculated. Crude birth rate, crude death rate, age specific mortality rate and sex specific mortality rate are some of the examples of the indicators that could be calculated. Vital statistics: This is a system by which all births and deaths occurring nationnwide are registered, reported and compiled centrally. There is no nationwide birth and death registration system in Ethiopia but the system should be established in the future. The main characteristics of vital statistics are: Comprehensive – all births and deaths should be registered. Health Service Records All health institutions report their activities to the Ministry of Health through the regional health bureaus. Advantages: Easily obtainable Available at low cost Continuous system of reporting Causes of illness and death available. The major problems related to this source (health service records) are low compliance and delays in reporting. Health Surveys Health surveys are studies conducted on a representative sample population to obtain more comprehensive data for monitoring the health status of a population. Advantages of surveys based on interview: They are more representative of the health condition of the community. Documentary sources - Clinical records and other personal records, death certificates, publications etc. If you want to know the number of people in your kebele who are properly using latrines, which method of data collection would be appropriate? When the disease occur as epidemic, outbreak, and pandemic it is considered as excess of what is expected. Epidemic: The occurrence of disease or other health related condition in excess of the usual frequency in a given area or among a specific group of people over a particular period of time. There is no general rule about the number of cases that must exist for a disease to be considered an epidemic. If the number of cases exceeds the expected level on the basis of the past experience of the particular population, then it is an epidemic. An epidemic may cover a small area within a city, or an entire nation or may have a worldwide distribution. Common Source Epidemics:- Disease occurs as a result of exposure of a group of susceptible persons to a common source of a pathogen, often at the same time or within a brief time period. When the exposure is simultaneous, the resulting cases develop within one incubation period of the disease and this is called a point source epidemic. Food borne epidemic following an event where the food was served to many people is a good example of point source epidemic. If the exposure to a common source continues over time it will result in a continuous common source epidemic. A waterborne outbreak that spreads through a contaminated community water supply is an example of a common source epidemic with continuous exposure. The epidemic curve may 55 have a wide peak because of the range of exposures and the range of incubation periods. It can occur through direct person to person transmission or it can involve more complex cycles in which the agent must pass through a vector as in malaria. Propagated spread usually results in an epidemic curve with a relatively gentle upslope and somewhat steeper tail.

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HbF contain 2 γ and 2 γ subunits in most adult often increases up to 15 - 20% in individuals with mutant adult Hbs safe trazodone 100 mg treatment quadratus lumborum, such as sickle cell disease order 100mg trazodone with visa treatment yeast infection. The direct benefit of this structural change in Hb isoform is a more efficient transfer of O2 from maternal HbA to fetal( HbF) order 100 mg trazodone amex treatment 0f osteoporosis. Sickle Cell Hemoglobin (HbS) HbS buy 100mg trazodone amex treatment neuroleptic malignant syndrome, the variant most commonly associated with sickle cell disease, cannot tolerate high protein concentration when deoxygenated. At low oxygen concentrations, deoxy HbS polymerizes, forms fibers, and distorts erythrocytes in to sickle shapes. Sickle Cell Trait The heterozygote individuals (sickle cell trait) (HbA/HbS) is associated with increased resistance to malaria. Sickled erythrocyte exhibits little or less deformity, they no longer move freely through the micorvasculature and often block blood flow. Moreover this cells lose water, become fragile and have a considerably short life span leading to anemia. Sickle Cell Disease Sickle cell disease is caused by an inherited structural abnormality in the β –globin polypeptide. Clinically, an individual with sickle cell disease present with intermittent episode of haemolytic and painful vaso–occlusive crisis. There is also a likely to be impaired growth, increased susceptibility to infections and multiple organ damage. Digestion and Absorption of Proteins Proteins are larger polypeptide molecules coiled by weaker bonds in their tertiary structure the digestion of proteins involves the gradual breakdown of this polypeptide by enzymatic hydrolysis in to amino acid molecules which are absorbed in the blood stream. The protein load received by the gut is derived from two sources 70-100g dietary protein which is required daily and 35 - 200g endogenous protein (secreted enzymes and proteins in the gut or from intestinal epithelia cell turnover) Only 1-2g of nitrogen equivalent to 6-12g of proteins are lost in the feces on a daily basis. Gastric Digestion Entry of a protein in to stomach stimulates the gastric mucosa to secrete a hormone gastrin which in turn stimulates the secretion of Hcl by the parietal cells of the gastric glands and pepsinogen by the chief cells. The acid denatures the protein and the whole protein susceptible to hydrolysis by the action other proteolytic enzymes. This active pepsin cleaves the ingested protein at their amino terminus of aromatic amino acids (Phe, Tyr, and Trp. Pancreatic Digestion Pancreatic zymogens proceed digestion as the acidic stomach contents pass in to the small intestine, A low pH triggers the secretion of a hormone Secretin in the blood. Three of these pro-enzyme are trypsinogen, chymotrypsinogen and procarboxy peptidase, localized in the exocrine cells. Synthesis of these enzymes as inactive precursors protects the exocrine cells from destructive proteolytic attack. By the sequential action of these proteolytic enzymes and peptides ingested proteins are hydrolyzed to yield a mixture of free amino acids which can be transported across the epithelial lining of the small intestine. Intestinal Digestion Since pancreatic juice does not contain appreciable aminopeptidase activity final digestion of di and Oligopeptides depends on the small intestinal enzymes. The lumenal surface of epithelial cells is rich in endopeptidase, and dipptidase aminopeptidase activity The end products of the cell surface digestion are free amino acids and di and tripeptides. From both genetic and transporters studies at least six specific symporter systems have been identified for the uptake of L-amino acids from the intestinal lumen. These transporter systems are also present in the renal tubules and defects in their constituent protein structure can lead to disease called Hartnup disease. Neutral amino Aciduria (Hartnup Disease) Transport functions, like enzymatic functions, are subject to modification by mutations. An example of a genetic lesion in epithelial amino acid transport is hartnup disease; entry resulting from the defect was first recognized. The disease is characterized by the inability of renal and intestinal epithelial cells to absorb neutral amino acids from the lumen. In the kidney, in which plasma amino acids reach the lumen of the proximal tubule through the Ultra filtrate, the inability to reabsorb amino acids manifests itself as excretion of amino acids in the Urine (aminoaciduria). Therefore the clinical symptoms of patients with this are mainly those due to essential amino acid and Nicotinamide deficiencies. The pellagra-like features are explained by a deficiency of Tryptophan, which serves as precursor for nicotinamide. Investigations of patients with Hartnup disease revealed the existence of intestinal transport systems for di - or tripeptides, which are different from the ones for free amino acids. The genetic lesion does not affect transport of peptides, which remains as a pathway for absorption of protein digestion products. Amino Acid Catabolism Transamination The nitrogen component of amino acids, the α - amino groups, must be removed before the carbons can be used in other metabolic pathways. The first step in the catabolism of most amino acids is the transfer of their α - amino group to α - ketoglutarate where the products are α - ketoacids and glutamate. This transfer of amino groups from one carbon skeleton to another is catalyzed by a family of transaminases which are also 141 called as aminotransferases. Alanine + α-Ketoglutarate <-> Pyruvate + Glutamate Oxaloacetate + Glutamate <-> Aspartate +-ketoglutarate (Urea cycle) In addition to their roles as building blocks of proteins, the carbon skeletons may be used to produce energy in oxidative metabolism by the end stages of glycolysis (such as pyruvate from Alanine) and tricarboxylic acid (such as oxaloacetate from Asparate) thereby providing a metabolic fuel for tissues that requre or prefer glucose. In addition, the carbon skeletons of certain amino acids can produce the equivalent of acetyl-CoA or Acetoacetate termed Ketogenic, indicating that they can be metabolized to give immediate precursor of lipids or ketone bodies. Assays of these enzyme activities in blood serum can be used both in diagnosis and in monitoring the progress of a patient during treatment. The functional part of pyridoxal phosphate is an aldehyde functional group attached to a pyridine ring. In a well fed condition, exreted nitrogen comes from digestion of excess protein or from normal turnover. During starvation the carbon skeleton of most amino acids from proteins fed in to gluconeogenesis to maintain the blood glucose level ; in this process ammonia is released and excreted mostly as urea and is not reincorporated in to protein. A diet deficient in an essential amino acid also leads to a negative nitrogen balance since body proteins are degraded to provide the deficient essential amino acid. Positive nitrogen balance occurs in growing children who are increasing their body weight and incorporating more amino acids in to protein than they breakdown. Cysteine and Arginine are 144 not essential in adults but essential in children because they are synthesized from Methionine and ornithine. Negative Nitrogen balance occurs in injury when there is net destruction of tissue and in major trauma or illness. Nitrogen Excretion and the Urea Cycle: Excess amino Nitrogen from amino acids is removed as ammonia, which is toxic to the human body. Some ammonia is excreted in urine, but nearly 90% of it is utilized by the liver to form urea, which is highly soluble and is passed in to circulation for being excreted by the kidneys. The urea-cycle starts in the mitochondrial matrix of hepatocytes and few of the steps occur in the cytosol: the cycle spans two cellular compartments. Some ammonia also arrives at the liver via the portal vein from the intestine, when it is produced by bacterial oxidation of amino acids. Carbamoyl phosphate reacts with ornithine transferring the carbamoyl moiety to produce citrulline: by the enzyme i. Ornithine is thus re-generated and can be transported in to the mitochondrion to initiate another round of the urea - cycle. Energetics of the urea cycle If the urea cycle is considered in isolation, the synthesis of one molecule of urea require four high energy phosphate groups 1. All the five enzymes are synthesized at higher rates in starving animals and in animals on a very high protein diet than well fed animals eating primarily carbohydrates and fats. Ammonia intoxication can be caused by inherited or acquired defects in ammonia trapping or in urea cycle most of the inhabited defects occur at a rate of 1 in every 30,000 births all. Ammonia intoxication caused by inherited defects in the urea cycle enzyme after arginosuccenate synthase can be treated by a diet low in protein and amino acid and supplemented by Arginine and citrulline. Treatment with sodium benzoate can produce additional disposal of non-urea nitrogen by combining with glycine the product hippuric acid, is excreted in the urine. Sodium phenyl lactate is even more effective, since it condenses with glutamine, the major carrier of excess Nitrogen. Acquired defects in urea–cycle Any disease or condition that adversely affects liver mitochondria can also produce an increased level of ammonia in the blood such condition include liver cirrhosis, alcoholism, hepatitis, and Reye’s syndromes.

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If there are no cancerous cells on the outer rim of the removed tissue it is described as clear cheap trazodone 100mg with mastercard symptoms lead poisoning, it there is cancerous cells present it is called positive and if there is cancerous cells close to the edge it is called close order 100mg trazodone symptoms congestive heart failure. Vascular or Lymphatic Invasion Describes whether the cancerous cells have infiltrated the vascular/lymphatic system supplying the breast buy trazodone 100 mg low cost medications when pregnant. Ploidy Diploid cancers cells have the same amount of chromosomes as normal cells and tend to be slower growing order trazodone 100 mg on-line medications ranitidine, less aggressive cells. Aneuploid cancer cells have too many/too little amount of chromosomes and tend to be rapid growing aggressive cells. 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. It is recommended if the cancer is at an early stage, 4 cm or smaller, located in one site, removed with clear margins. It is also recommended after a mastectomy if: 36 - The cancer is 5 centimetres or larger. It is usually given on most days of the week for 5-7 weeks in an outpatient setting, but this may differ between patients. Side effects  Skin colour changes  Itching, burning, blistering, peeling, irritation/discomfort/pain over radiation site  Chest pain  Fatigue  Low white blood cell count  Cardiac complications  Pulmonary complications (especially pulmonary fibrosis)  Although now considered very rare, brachial plexopathies have historically been shown to develop up to 20 years post radiotherapy (Hayes et al, 2012). Psychological Impact Patients can have high levels of anxiety prior to starting radiotherapy. The most common source of anxiety for women is the effects of radiation on their future health (Halkett et al 2012).

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This finding highlights the importance of giving greater attention to this group of patients in terms of treatment discount 100 mg trazodone overnight delivery medicine 2632, reporting generic trazodone 100mg mastercard 4 medications list, and representative drug resistance surveillance cheap trazodone 100 mg line medications 2355. In general generic trazodone 100mg free shipping lb 95 medications, the ecological analysis was inconclusive with the exception of the above finding. Despite the inherent weakness in ecological analysis of aggregate data, the conceptual model can constitute a step forward for more reliable and individual data collection. Ultimately the magnitude of the problem rests on the ability of a country to treat patients effectively. Failure to do so will result in a situation where a substandard level of care and irrational use of second-line drugs will continue to perpetuate the transmission of, and potentially amplify further, highly drug-resistant isolates of tuberculosis. The network has completed nine rounds of proficiency testing since 1994; cumulative results over the nine rounds generally indicate overall high performance of the network. Following an evaluation by the supranational laboratory, a decision is made on whether to carry out the survey or repeat proficiency testing. The network has recently agreed such criteria and details will be published in the coming year. Preliminary research has shown that at least one of the apparently borderline isolates was in fact a mixed culture containing one drug-resistant and one susceptible isolate; however, further exploration is warranted. There is a need for these costs to be met internationally to stabilize and enhance the network. The Laboratory Strengthening Subgroup seeks to assess and develop plans for improvement of entire national laboratory networks, with an emphasis on sputum smear microscopy. Improved laboratory networks will translate into improved diagnostic and treatment capacity, and more accurate surveillance of drug resistance. This is not always true of the data from individual sites, where the number of cultures examined is less than 1000, given that some drug resistance types show prevalences of 0. The total number of isolates examined is sufficiently high to guarantee statistical significance of both new cases and previously treated cases, even though all settings within some regions such as the Eastern Mediterranean and South-East Asia are not necessarily representative of the regions as a whole. The consistency of the findings argues for the robustness of the following conclusions. In patients with drug-resistant tuberculosis, additional drug resistance may develop if a prescribed multidrug regimen includes the drugs these patients are already resistant to. In this situation, some of these patients may end up effectively receiving monotherapy. In this respect the findings of worldwide drug resistance surveys are revealing, in that the prevalence of drug resistance is significantly higher among previously treated patients than among new patients in all regions. The only logical inference is that present treatment practices create significant numbers of new resistant cases and amplify already present resistance. This analysis shows a remarkable consistency, both globally and regionally, in the distribution of the major drug resistance types, as well as in the increase in drug resistance prevalence among previously treated cases relative to new cases. It should be noted that prevalence of drug resistance observed in previously treated cases is higher than in new cases in all regions. Since this difference is in great part directly related to the quality of drug treatment, this apparent characteristic could well lead to the development of an indicator that would measure the quality of treatment practices. The addition of a new drug to a failing drug regimen is an effective way of amplifying the drug resistance problem. Monoresistance can only be selected in the presence of a drug concentration leading to the selection of pre-existing mutant bacilli, whereas resistance to two drugs cannot be created simultaneously in the presence of effective concentrations of two drugs. This is because the number of bacilli present in the lesions (108) is usually much lower than the theoretically required bacillary load needed to produce double resistance, i. Results obtained in this study show that the proportions of monoresistance are lower in patients having re-treatment, whereas double resistance remains essentially unchanged. Triple and quadruple resistance are higher by about the same proportion as monoresistance is lower. Amplification caused by re-treatment is the easiest way to interpret these changes, i. The absence of a significant change in double resistance proportions can be explained by selective pressure, leading to an increase in triple and quadruple drug resistance modes thus balancing the inflow from the monoresistance mode. Since resistance in re-treatment cases mostly reflects the quality of recent treatment, these results could lead to the development of an indicator, based on the extent of amplification. The difference between previously treated and new case triple and quadruple resistance proportions could constitute such an indicator. Other pathways can and do exist but their contribution to the drug resistance problem is relatively minor. We can therefore state that monoresistance to H or to S is the foundation for the acquisition of additional drug resistance. Implications The above analysis has shown that there is circumstantial but compelling evidence that either monotherapy or “effective” monotherapy, or both, are more widespread than commonly thought. These results corroborate recently emerging evidence that standard re-treatment regimens containing first-line drugs for failures of standard treatment should be abandoned in some settings. One possible way of breaking the amplification juggernaut would be to replace S in standard regimens and/or to add a third drug to the continuation phase. It expresses the percentage of the variation in the outcome variable that has been explained by the regression on the explanatory variables. For countries conducting surveys on a sample of the population, estimates were generated by applying prevalences determined in surveys to reported notification figures for the corresponding population and thus are dependent upon the level of case-finding in the country and quality of recording and reporting of the national programme. For countries conducting surveys on a sample of the population, estimates were generated by applying prevalences determined in surveys to reported notification figures for the corresponding population and thus are dependent upon the level of case-finding in the country and quality of recording and reporting of the national programme. Epidemiological and clinical study of tuberculosis in the district of Kolín, Czechoslovakia. Evaluating the impact of tuberculosis control: number of deaths prevented by short-course chemotherapy in China. Development of streptomycin resistant isolates of tubercle bacilli in pulmonary tuberculosis. Drug resistance in patients with pulmonary tuberculosis presenting at chest clinics in Hong Kong. Relative numbers of resistant tubercle bacilli in sputa of patients before and during treatment with streptomycin. Bacteriological aspects of the use of ethionamide, pyrazinamide and cycloserine in the treatment of chronic pulmonary tuberculosis. Involving private practitioners in tuberculosis control: issues, interventions, and emerging policy framework. Purchase of antibiotics without prescription in Manila, the Philippines: inappropriate choices and doses. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1982, 79:679-691. A survey of prescribing patterns for tuberculosis treatment amongst doctors in a Bolivian city. Initial drug regimens for the treatment of tuberculosis: evaluation of physician prescribing practice in New Jersey, 1994-1995. Standard short-course chemotherapy for drug-resistant tuberculosis: Treatment Outcomes in 6 Countries. Increasing transparency in partnerships for health: introducing the Green Light Committee. The impact of human immunodeficiency virus infection on drug resistant tuberculosis. An outbreak of multi-drug resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. 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.

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