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By G. Aila. Maryland Institute, College of Art.

Maintaining these normal concentrations of testosterone promotes spermatogenesis purchase diclofenac 100 mg mastercard, whereas low levels of testosterone can lead to infertility buy generic diclofenac 50mg on-line. In addition to intratesticular secretion discount 100mg diclofenac otc, testosterone is also released into the systemic circulation and plays an important role in muscle development, bone growth, the development of secondary sex characteristics, and maintaining libido (sex drive) in both males and females. In females, the ovaries secrete small amounts of testosterone, although most is converted to estradiol. Control of Testosterone The regulation of testosterone concentrations throughout the body is critical for male reproductive function. The intricate interplay between the endocrine system and the reproductive system is shown in Figure 27. The hypothalamus and the pituitary gland in the brain integrate external and internal signals to control testosterone synthesis and secretion. These polypeptide hormones correlate directly with Sertoli cell function and sperm number; inhibin B can be used as a marker of spermatogenic activity. The resulting reduction in circulating testosterone concentrations can lead to symptoms of andropause, also known as male menopause. While the reduction in sex steroids in men is akin to female menopause, there is no clear sign—such as a lack of a menstrual period—to denote the initiation of andropause. Instead, men report feelings of fatigue, reduced muscle mass, depression, anxiety, irritability, loss of libido, and insomnia. A reduction in spermatogenesis resulting in lowered fertility is also reported, and sexual dysfunction can also be associated with andropausal symptoms. Whereas some researchers believe that certain aspects of andropause are difficult to tease apart from aging in general, testosterone replacement is sometimes prescribed to alleviate some symptoms. Recent studies have shown a benefit from androgen replacement therapy on the new onset of depression in elderly men; however, other studies caution against testosterone replacement for long-term treatment of andropause symptoms, showing that high doses can sharply increase the risk of both heart disease and prostate cancer. Unlike its male counterpart, the female reproductive system is located primarily inside the pelvic cavity (Figure 27. External Female Genitals The external female reproductive structures are referred to collectively as the vulva (Figure 27. The labia majora (labia = “lips”; majora = “larger”) are folds of hair-covered skin that begin just posterior to the mons pubis. The thinner and more pigmented labia minora (labia = “lips”; minora = “smaller”) extend medial to the labia majora. Although they naturally vary in shape and size from woman to woman, the labia minora serve to protect the female urethra and the entrance to the female reproductive tract. The superior, anterior portions of the labia minora come together to encircle the clitoris (or glans clitoris), an organ that originates from the same cells as the glans penis and has abundant nerves that make it important in sexual sensation and orgasm. An intact hymen cannot be used as an indication of “virginity”; even at birth, this is only a partial membrane, as menstrual fluid and other secretions must be able to exit the body, regardless of penile–vaginal intercourse. The outer walls of the anterior and posterior vagina are formed into longitudinal columns, or ridges, and the superior portion of the vagina—called the fornix—meets the protruding uterine cervix. The walls of the vagina are lined with an outer, fibrous adventitia; a middle layer of smooth muscle; and an inner mucous membrane with transverse folds called rugae. Together, the middle and inner layers allow the expansion of the vagina to accommodate intercourse and childbirth. The hymen can be ruptured with strenuous physical exercise, penile–vaginal intercourse, and childbirth. The Bartholin’s glands and the lesser vestibular glands (located near the clitoris) secrete mucus, which keeps the vestibular area moist. The vagina is home to a normal population of microorganisms that help to protect against infection by pathogenic bacteria, yeast, or other organisms that can enter the vagina. This family of beneficial bacterial flora secretes lactic acid, and thus protects the vagina by maintaining an acidic pH (below 4. However, douching—or washing out the vagina with fluid—can disrupt the normal balance of healthy microorganisms, and actually increase a woman’s risk for infections and irritation. Indeed, the American College of Obstetricians and Gynecologists recommend that women do not douche, and that they allow the vagina to maintain its normal healthy population of protective microbial flora. The ovaries are located within the pelvic cavity, and are supported by the mesovarium, an extension of the peritoneum that connects the ovaries to the broad ligament. Extending from the mesovarium itself is the suspensory ligament that contains the ovarian blood and lymph vessels. The ovary comprises an outer covering of cuboidal epithelium called the ovarian surface epithelium that is superficial to a dense connective tissue covering called the tunica albuginea. The cortex is composed of a tissue framework called the ovarian stroma that forms the bulk of the adult ovary. Beneath the cortex lies the inner ovarian medulla, the site of blood vessels, lymph vessels, and the nerves of the ovary. You will learn more about the overall anatomy of the female reproductive system at the end of this section. During a woman’s reproductive years, it is a roughly 28-day cycle that can be correlated with, but is not the same as, the menstrual cycle (discussed shortly). The cycle includes two interrelated processes: oogenesis (the production of female gametes) and folliculogenesis (the growth and development of ovarian follicles). Oogonia are formed during fetal development, and divide via mitosis, much like spermatogonia in the testis. These primary oocytes are then arrested in this stage of meiosis I, only to resume it years later, beginning at puberty and continuing until the woman is near menopause (the cessation of a woman’s reproductive functions). The number of primary oocytes present in the ovaries declines from one to two million in an infant, to approximately 400,000 at puberty, to zero by the end of menopause. The initiation of ovulation—the release of an oocyte from the ovary—marks the transition from puberty into reproductive maturity for women. From then on, throughout a woman’s reproductive years, ovulation occurs approximately once every 28 days. Just prior to ovulation, a surge of luteinizing hormone triggers the resumption of meiosis in a primary oocyte. The smaller cell, called the first polar body, may or may not complete meiosis and produce second polar bodies; in either case, it eventually disintegrates. Thus, the ovum can be thought of as a brief, transitional, haploid stage between the diploid oocyte and diploid zygote. The larger amount of cytoplasm contained in the female gamete is used to supply the developing zygote with nutrients during the period between fertilization and implantation into the uterus. Therefore, the cytoplasm and all of the cytoplasmic organelles in the developing embryo are of maternal origin. By analyzing these mutational relationships, researchers have been able to determine that we can all trace our ancestry back to one woman who lived in Africa about 200,000 years ago. Scientists have given this woman the biblical name Eve, although she is not, of course, the first Homo sapiens female. They grow and develop in a process called folliculogenesis, which typically leads to ovulation of one follicle approximately every 28 days, along with death to multiple other follicles. The death of ovarian follicles is called atresia, and can occur at any point during follicular development. Recall that, a female infant at birth will have one to two million oocytes within her ovarian follicles, and that this number declines throughout life until menopause, when no follicles remain.

H R E S H R New Zealand Countrywide 2006 Surveillance 250 224 89 generic 100 mg diclofenac with visa,6 26 10 buy diclofenac 100 mg fast delivery,4 17 6 buy cheap diclofenac 50mg,8 1 0,4 1 0,4 18 7,2 17 6,8 8 3,2 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance 18 4 22,2 4 22,2 3 16,7 2 11,1 0 0,0 2 11,1 1 5,6 0 0,0 0 0,0 Philippines Countrywide 2004 Survey 965 767 79,5 198 20,5 130 13,5 44 4,6 41 4,2 115 11,9 122 12,6 57 5,9 4 0,4 Rep. Vanuatu Countrywide 2006 Surveillance 29 28 96,6 1 3,4 1 3,4 0 0,0 0 0,0 0 0,0 1 3,4 1 3,4 0 0,0 Viet Nam Countrywide 2006 Survey 1619 1. The reduction would be 106 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 0 0,0 9 3,6 1 0,4 0 0,0 0 0,0 0 0,0 1 0,4 8 3,2 0 0,0 8 3,2 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 1 5,6 2 11,1 2 11,1 0 0,0 0 0,0 0 0,0 1 5,6 0 0,0 1 5,6 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 1 0,1 60 6,2 39 4,0 10 1,0 5 0,5 5 0,5 19 2,0 37 3,8 5 0,5 21 2,2 8 0,8 1 0,1 0 0,0 0 0,0 2 0,2 7 0,3 26 1,0 71 2,7 24 0,9 33 1,3 4 0,2 10 0,4 47 1,8 16 0,6 26 1,0 3 0,1 1 0,0 1 0,0 0 0,0 0 0,0 2 0,2 23 2,6 2 0,2 0 0,0 0 0,0 0 0,0 2 0,2 12 1,3 2 0,2 9 1,0 1 0,1 0 0,0 0 0,0 0 0,0 0 0,0. Ethiopia Countrywide 2005 Survey 76 39 51,3 37 48,7 19 25,0 11 14,5 11 14,5 29 38,2 21 27,6 4 5,3 1 1,3 Gambia Countrywide 2000 Survey 15 15 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Guinea Sentinel sites 1998 Survey 32 16 50,0 16 50,0 16 50,0 9 28,1 6 18,8 11 34,4 3 9,4 3 9,4 0 0,0 Kenya Nearly Countrywide 1995 Survey 46 29 63,0 17 37,0 17 37,0 0 0,0 0 0,0 3 6,5 14 30,4 14 30,4 0 0,0 Lesotho Countrywide 1995 Survey 53 35 66,0 18 34,0 16 30,2 3 5,7 2 3,8 9 17,0 11 20,8 9 17,0 0 0,0 Madagascar (2) Countrywide 2007 Survey 51 45 88,2 6 11,8 5 9,8 3 5,9 0 0,0 2 3,9 2 3,9 2 3,9 0 0,0 Mozambique Countrywide 1999 Survey 122 67 54,9 55 45,1 50 41,0 5 4,1 1 0,8 30 24,6 27 22,1 22 18,0 1 0,8 Rwanda Countrywide 2005 Survey 85 66 77,6 19 22,4 9 10,6 9 10,6 10 11,8 16 18,8 10 11,8 0 0,0 1 1,2 Senegal Countrywide 2006 Survey 42 29 69,0 13 31,0 10 23,8 7 16,7 7 16,7 12 28,6 4 9,5 1 2,4 0 0,0 Sierra Leone Nearly Countrywide 1997 Survey 13 5 38,5 8 61,5 8 61,5 3 23,1 1 7,7 3 23,1 4 30,8 4 30,8 0 0,0 South Africa Countrywide 2002 Survey 1465 1. Costa Rica Countrywide 2006 Survey 21 20 95,2 1 4,8 1 4,8 1 4,8 1 4,8 0 0,0 0 0,0 0 0,0 0 0,0 Cuba Countrywide 2005 Sentinel 19 12 63,2 7 36,8 2 10,5 1 5,3 0 0,0 6 31,6 6 31,6 1 5,3 0 0,0 Dominican Republic Countrywide 1995 Survey 117 56 47,9 61 52,1 43 36,8 37 31,6 15 12,8 30 25,6 26 22,2 12 10,3 10 8,5 Ecuador Countrywide 2002 Survey 185 104 56,2 81 43,8 56 30,3 62 33,5 10 5,4 38 20,5 24 13,0 5 2,7 11 5,9 El Salvador Countrywide 2001 Survey 100 78 78,0 22 22,0 12 12,0 13 13,0 3 3,0 9 9,0 12 12,0 3 3,0 5 5,0 Guatemala Countrywide 2002 Survey 155 70 45,2 85 54,8 56 36,1 45 29,0 31 20,0 67 43,2 34 21,9 6 3,9 3 1,9 Honduras Countrywide 2004 Survey 73 45 61,6 28 38,4 18 24,7 15 20,5 5 6,8 11 15,1 16 21,9 7 9,6 5 6,8 Mexico Baja California, 1997 Survey 107 63 58,9 44 41,1 35 32,7 30 28,0 15 14,0 20 18,7 16 15,0 11 10,3 2 1,9 Sinaloa, Oaxaca Nicaragua Countrywide 2006 Survey 103 66 64,1 37 35,9 30 29,1 9 8,7 9 8,7 21 20,4 18 17,5 11 10,7 1 1,0 Paraguay Countrywide 2001 Survey 51 41 80,4 10 19,6 6 11,8 6 11,8 1 2,0 2 3,9 7 13,7 3 5,9 4 7,8 Peru Countrywide 2006 Survey 360 210 58,3 150 41,7 109 30,3 95 26,4 33 9,2 107 29,7 52 14,4 13 3,6 8 2,2 Puerto Rico Countrywide 2005 Surveillance combined only. H R E S H R Iceland Countrywide 2005 Surveillance 1 1 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Ireland Countrywide 2005 Surveillance 10 8 80,0 2 20,0 2 20,0 1 10,0 0 0,0 0 0,0 1 10,0 1 10,0 0 0,0 Israel Countrywide 2005 Surveillance 3 3 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Italy Half of the country 2005 Surveillance 79 50 63,3 29 36,7 24 30,4 14 17,7 8 10,1 23 29,1 9 11,4 4 5,1 0 0,0 Kazakhstan Countrywide 2001 Survey 319 57 17,9 262 82,1 216 67,7 196 61,4 173 54,2 246 77,1 26 8,2 3 0,9 1 0,3 Latvia Countrywide 2005 Surveillance 182 86 47,3 96 52,7 90 49,5 66 36,3 63 34,6 93 51,1 9 4,9 3 1,6 0 0,0 Lithuania Countrywide 2005 Surveillance 440 176 40,0 264 60,0 250 56,8 212 48,2 239 54,3 141 32,0 27 6,1 14 3,2 2 0,5 Luxembourg Countrywide 2005 Surveillance 0 0 0 0 0 0 0 0 0 0 Malta Countrywide 2005 Surveillance 0 0 0 0 0 0 0 0 0 0 Netherlands Countrywide 2005 Surveillance 30 25 83,3 5 16,7 3 10,0 2 6,7 0 0,0 2 6,7 3 10,0 1 3,3 1 3,3 Norway Countrywide 2005 Surveillance 8 8 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Poland Countrywide 2004 Surveillance 522 428 82,0 94 18,0 71 13,6 51 9,8 12 2,3 55 10,5 39 7,5 17 3,3 7 1,3 Portugal Countrywide 2005 Surveillance 172 127 73,8 35 20,3 26 15,1 19 11,0 10 5,8 18 10,5 14 8,1 6 3,5 2 1,2 Republic of Moldova Countrywide 2006 Surveillance 2054 605 29,5 1. Serbia Countrywide 2005 Surveillance 121 107 88,4 14 11,6 7 5,8 8 6,6 6 5,0 6 5,0 7 5,8 2 1,7 1 0,8 Slovakia Countrywide 2005 Surveillance 56 46 82,1 10 17,9 10 17,9 4 7,1 1 1,8 3 5,4 3 5,4 3 5,4 0 0,0 Slovenia Countrywide 2005 Surveillance 28 24 85,7 4 14,3 3 10,7 1 3,6 1 3,6 3 10,7 2 7,1 1 3,6 0 0,0 Spain Galicia 2005 Surveillance 68 59 86,8 9 13,2 5 7,4 1 1,5 1 1,5 6 8,8 6 8,8 2 2,9 0 0,0 Spain Aragon 2005 Surveillance 26 21 80,8 5 19,2 5 19,2 4 15,4 2 7,7 2 7,7 1 3,8 1 3,8 0 0,0 Spain Barcelona 2005 Surveillance combined only. Kerala State India Gujarat State 2006 Survey 1047 562 53,7 485 46,3 385 36,8 190 18,1 105 10,0 274 26,2 220 21,0 122 11,7 10 1,0 India Tamil Nadu State 1997 Survey new only. H R E S H R Japan Countrywide 2002 Surveillance 417 312 74,8 105 25,2 79 18,9 46 11,0 35 8,4 60 14,4 49 11,8 26 6,2 2 0,5 Malaysia Peninsular Malaysia 1997 Survey 16 13 81,3 3 18,8 0 0,0 1 6,3 0 0,0 2 12,5 3 18,8 0 0,0 1 6,3 Mongolia Countrywide 1999 Survey new only. New Zealand Countrywide 2006 Surveillance 16 15 93,8 1 6,3 1 6,3 0 0,0 0 0,0 0 0,0 1 6,3 1 6,3 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance new only. Philippines Countrywide 2004 Survey 129 81 62,8 48 37,2 40 31,0 33 25,6 12 9,3 22 17,1 17 13,2 10 7,8 5 3,9 Rep. Korea Countrywide 2004 Survey 278 201 72,3 77 27,7 67 24,1 47 16,9 27 9,7 16 5,8 29 10,4 20 7,2 7 2,5 Singapore Countrywide 2005 Surveillance 105 94 89,5 11 10,5 4 3,8 3 2,9 1 1,0 7 6,7 9 8,6 2 1,9 2 1,9 Solomon Islands Countrywide 2004 Survey combined only. Viet Nam Countrywide 2006 Survey 207 85 41,1 122 58,9 90 43,5 44 21,3 30 14,5 105 50,7 38 18,4 8 3,9 2 1,0 (1) Several countries conducting routine diagnostic surveillance do not routinely test for streptomycin. The reduction would be 112 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 1 0,2 20 4,8 41 9,8 6 1,4 6 1,4 10 2,4 19 4,6 15 3,6 3 0,7 6 1,4 3 0,7 1 0,2 0 0,0 2 0,5 0 0,0 0 0,0 2 12,5 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0. Costa Rica Countrywide 2006 Survey 284 264 93,0 20 7,0 10 3,5 6 2,1 14 4,9 0 0,0 7 2,5 5 1,8 1 0,4 Cuba Countrywide 2005 Sentinel 198 177 89,4 21 10,6 3 1,5 2 1,0 0 0,0 19 9,6 19 9,6 1 0,5 1 0,5 Dominican Republic Countrywide 1995 Survey 420 236 56,2 184 43,8 103 24,5 86 20,5 26 6,2 94 22,4 104 24,8 38 9,0 31 7,4 Ecuador Countrywide 2002 Survey 997 753 75,5 244 24,5 145 14,5 121 12,1 20 2,0 130 13,0 123 12,3 34 3,4 26 2,6 El Salvador Countrywide 2001 Survey 711 654 92,0 57 8,0 20 2,8 20 2,8 5 0,7 32 4,5 42 5,9 6 0,8 10 1,4 Guatemala Countrywide 2002 Survey 823 505 61,4 318 38,6 128 15,6 73 8,9 83 10,1 260 31,6 190 23,1 14 1,7 8 1,0 Honduras Countrywide 2004 Survey 530 447 84,3 83 15,7 45 8,5 25 4,7 13 2,5 49 9,2 55 10,4 18 3,4 7 1,3 Mexico Baja California, 1997 Survey 441 350 79,4 91 20,6 59 13,4 42 9,5 25 5,7 44 10,0 51 11,6 25 5,7 4 0,9 Sinaloa, Oaxaca Nicaragua Countrywide 2006 Survey 423 344 81,3 79 18,7 51 12,1 12 2,8 13 3,1 46 10,9 51 12,1 24 5,7 2 0,5 Paraguay Countrywide 2001 Survey 286 250 87,4 36 12,6 21 7,3 14 4,9 7 2,4 14 4,9 23 8,0 10 3,5 7 2,4 Peru Countrywide 2006 Survey 2169 1. H R E S H R Iceland Countrywide 2005 Surveillance 8 8 100,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0 Ireland Countrywide 2005 Surveillance 273 260 95,2 13 4,8 13 4,8 3 1,1 2 0,7 3 1,1 9 3,3 9 3,3 0 0,0 Israel Countrywide 2005 Surveillance 217 171 78,8 46 21,2 32 14,7 12 5,5 13 6,0 41 18,9 15 6,9 2 0,9 0 0,0 Italy Half of the country 2005 Surveillance 585 504 86,2 81 13,8 57 9,7 26 4,4 13 2,2 52 8,9 44 7,5 22 3,8 2 0,3 Kazakhstan Countrywide 2001 Survey 678 211 31,1 467 68,9 369 54,4 252 37,2 262 38,6 431 63,6 76 11,2 14 2,1 2 0,3 Latvia Countrywide 2005 Surveillance 1055 646 61,2 409 38,8 360 34,1 160 15,2 155 14,7 366 34,7 89 8,4 40 3,8 0 0,0 Lithuania Countrywide 2005 Surveillance 1739 1. Papua Province Myanmar Countrywide 2003 Survey 849 741 87,3 108 12,7 79 9,3 52 6,1 10 1,2 74 8,7 33 3,9 9 1,1 0 0,0 Nepal Countrywide 2007 Survey 930 776 83,4 154 16,6 101 10,9 41 4,4 43 4,6 113 12,2 80 8,6 27 2,9 0 0,0 Sri Lanka Countrywide 2006 Survey 624 613 98,2 11 1,8 6 1,0 3 0,5 1 0,2 5 0,8 9 1,4 4 0,6 2 0,3 Thailand Countrywide 2006 Survey 1344 1. New Caledonia Countrywide 2005 Survey 5 4 80,0 1 20,0 1 20,0 0 0,0 0 0,0 1 20,0 0 0,0 0 0,0 0 0,0 New Zealand Countrywide 2006 Surveillance 266 239 89,8 27 10,2 18 6,8 1 0,4 1 0,4 18 6,8 18 6,8 9 3,4 0 0,0 Northern Mariana Is Countrywide 2006 Surveillance new only. Philippines Countrywide 2004 Survey 1094 848 77,5 246 22,5 170 15,5 77 7,0 53 4,8 137 12,5 139 12,7 67 6,1 9 0,8 Rep. The reduction would be 118 Mono % Mono % Mdr % Hr % Hre % Hrs % Hres % Poly % He % Hs % Hes % Re % Rs % Res % Es % E S 3 0,1 164 5,3 60 1,9 8 0,3 9 0,3 13 0,4 30 1,0 45 1,4 3 0,1 27 0,9 7 0,2 1 0,0 2 0,1 4 0,1 1 0,0 4 0,4 26 2,6 1 0,1 0 0,0 0 0,0 0 0,0 1 0,1 5 0,5 0 0,0 5 0,5 0 0,0 0 0,0 0 0,0 0 0,0 0 0,0. Puerto Rico Surveillance 132 18 13,6 3 2,3 158 19 12,0 8 5,1 166 18 10,8 3 1,8 193 26 13,5 5 2,6 165 15 9,1 3 1,8 175 13 7,4 1 0,6 Uruguay Survey. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimi- tation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Al-Suwaidi •Russian Federation (Orel): Dr Paul Arguin, Dr Evgenia Nemtsova, Dr Boris Kazzeony, Helen Kiryanova •Russian Federation (Tomsk): Dr Irena Gelmananova, Dr Donna Barry, Professor Mikhail I. This project could not have succeeded without the support of national authorities and the institutions hosting each of the national and international laboratories. A special acknowledgement is due to Dan Bleed and Mehran Hosseini for technical support of data management. 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. Data were reported on a standard reporting form, either annually or at the completion of the survey. The prevalence of resistance to at least one antituberculosis drug (any a Setting is defined as a country or a subnational setting (i. Trends in drug resistance in new cases were determined in 46 settings (20 with two data points and 26 with at least three). Significant increases in prevalence of any resistance were found in Botswana, New Zealand, Poland, and Tomsk Oblast (Russian Federation). Previously treated cases Data on previously treated cases were available for 66 settings.

At a synovial joint buy diclofenac us, the articulating surfaces of the bones are not directly connected buy diclofenac 100mg fast delivery, but instead come into contact with each other within a joint cavity that is filled with a lubricating fluid generic diclofenac 100mg without a prescription. Functional Classification of Joints The functional classification of joints is determined by the amount of mobility found between the adjacent bones. Joints are thus functionally classified as a synarthrosis or immobile joint, an amphiarthrosis or slightly moveable joint, or as a diarthrosis, which is a freely moveable joint (arthroun = “to fasten by a joint”). Depending on their location, fibrous joints may be functionally classified as a synarthrosis (immobile joint) or an amphiarthrosis (slightly mobile joint). Cartilaginous joints are also functionally classified as either a synarthrosis or an amphiarthrosis joint. Examples include sutures, the fibrous joints between the bones of the skull that surround and protect the brain (Figure 9. An example of this type of joint is the cartilaginous joint that unites the bodies of adjacent vertebrae. Filling the gap between the vertebrae is a thick pad of fibrocartilage called an intervertebral disc (Figure 9. Each intervertebral disc strongly unites the vertebrae but still allows for a limited amount of movement between them. However, the small movements available between adjacent vertebrae can sum together along the length of the vertebral column to provide for large ranges of body movements. This is a cartilaginous joint in which the pubic regions of the right and left hip bones are strongly anchored to each other by fibrocartilage. The strength of the pubic symphysis is important in conferring weight-bearing stability to the pelvis. Each disc allows for limited movement between the vertebrae and thus functionally forms an amphiarthrosis type of joint. Intervertebral discs are made of fibrocartilage and thereby structurally form a symphysis type of cartilaginous joint. These types of joints include all synovial joints of the body, which provide the majority of body movements. Most diarthrotic joints are found in the appendicular skeleton and thus give the limbs a wide range of motion. These joints are divided into three categories, based on the number of axes of motion provided by each. An axis in anatomy is described as the movements in reference to the three anatomical planes: transverse, frontal, and sagittal. Thus, diarthroses are classified as uniaxial (for movement in one plane), biaxial (for movement in two planes), or multiaxial joints (for movement in all three anatomical planes). The joint allows for movement along one axis to produce bending or straightening of the finger, and movement along a second axis, which allows for spreading of the fingers away from each other and bringing them together. A joint that allows for the several directions of movement is called a multiaxial joint (polyaxial or triaxial joint). They allow the upper or lower limb to move in an anterior- posterior direction and a medial-lateral direction. This third movement results in rotation of the limb so that its anterior surface is moved either toward or away from the midline of the body. At a syndesmosis joint, the bones are more widely separated but are held together by a narrow band of fibrous connective tissue called a ligament or a wide sheet of connective tissue called an interosseous membrane. This type of fibrous joint is found between the shaft regions of the long bones in the forearm and in the leg. Lastly, a gomphosis is the narrow fibrous joint between the roots of a tooth and the bony socket in the jaw into which the tooth fits. Suture All the bones of the skull, except for the mandible, are joined to each other by a fibrous joint called a suture. The fibrous connective tissue found at a suture (“to bind or sew”) strongly unites the adjacent skull bones and thus helps to protect the brain and form the face. In adults, the skull bones are closely opposed and fibrous connective tissue fills the narrow gap between the bones. The suture is frequently convoluted, forming a tight union that prevents most movement between the bones. In newborns and infants, the areas of connective tissue between the bones are much wider, especially in those areas on the top and sides of the skull that will become the sagittal, coronal, squamous, and lambdoid sutures. During birth, the fontanelles provide flexibility to the skull, allowing the bones to push closer together or to overlap slightly, thus aiding movement of the infant’s head through the birth canal. After birth, these expanded regions of connective tissue allow for rapid growth of the skull and enlargement of the brain. The fontanelles greatly decrease in width during the first year after birth as the skull bones enlarge. When the connective tissue between the adjacent bones is reduced to a narrow layer, these fibrous joints are now called sutures. At some sutures, the connective tissue will ossify and be converted into bone, causing the adjacent bones to fuse to each other. At the time of birth, the frontal and maxillary bones consist of right and left halves joined together by sutures, which disappear by the eighth year as the halves fuse together to form a single bone. Late in life, the sagittal, coronal, and lambdoid sutures of the skull will begin to ossify and fuse, causing the suture line to gradually disappear. Syndesmosis A syndesmosis (“fastened with a band”) is a type of fibrous joint in which two parallel bones are united to each other by fibrous connective tissue. The gap between the bones may be narrow, with the bones joined by ligaments, or the gap may be wide and filled in by a broad sheet of connective tissue called an interosseous membrane. In the forearm, the wide gap between the shaft portions of the radius and ulna bones are strongly united by an interosseous membrane (see Figure 9. Similarly, in the leg, the shafts of the tibia and fibula are also united by an interosseous membrane. In addition, at the distal tibiofibular joint, the articulating surfaces of the bones lack cartilage and the narrow gap between the bones is anchored by fibrous connective tissue and ligaments on both the anterior and posterior aspects of the joint. The syndesmoses found in the forearm and leg serve to unite parallel bones and prevent their separation. However, a syndesmosis does not prevent all movement between the bones, and thus this type of fibrous joint is functionally classified as an amphiarthrosis. In the leg, the syndesmosis between the tibia and fibula strongly unites the bones, allows for little movement, and firmly locks the talus bone in place between the tibia and fibula at the ankle joint. In the forearm, the interosseous membrane is flexible enough to allow for rotation of the radius bone during forearm movements. Thus in contrast to the stability provided by the tibiofibular syndesmosis, the flexibility of the antebrachial interosseous membrane allows for the much greater mobility of the forearm. Damage to a syndesmotic joint, which usually results from a fracture of the bone with an accompanying tear of the interosseous membrane, will produce pain, loss of stability of the bones, and may damage the muscles attached to the interosseous membrane. If the fracture site is not properly immobilized with a cast or splint, contractile activity by these muscles can cause improper alignment of the broken bones during healing.

Adherence to physicians’ instructions as a factor in managing streptococcal pharyngitis buy 100mg diclofenac. A long term epidemiological study of subsequent prophylaxis buy 100 mg diclofenac with visa, streptococcal infections order 100mg diclofenac with visa, and clinical sequelae. Comparative effectiveness of three prophylaxis regimens in preventing streptococcal infections and rheumatic recurrences. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Drugs used in the treatment of streptococcal pharyngitis and prevention of rheumatic fever. Pharmacokinetics of benzathine penicillin G: serum levels during the 28 days after intramuscular injection of 1200000 units. Allergic reactions to long-term benzathine penicillin prophylaxis for rheumatic fever. Allergic reactions in rheumatic fever patients on long- term benzathine penicillin G: the role of skin testing for penicillin allergy. Nature and extent of penicillin reactions, with particular reference to fatalities from anaphylactic shock. The value of skin testing for penicillin allergy in inpatient population: analisis of the subsequent patient management. Introduction of a practice guidelines for penicillin skin testing improves the appropriateness of antibiotic therapy. For these patients, prophylaxis for the infective endocarditis is thus recommended. Infective endocarditis rarely occurs without underlying cardiac pa- thology, either congenital or acquired. Even though these indi- viduals usually have normal valvular anatomy, infective endocarditis is not uncommon in this group, particularly of the tricuspid valve. Patients with congenital heart disease also have a higher risk of devel- oping endocarditis. Although a discussion of the risks of infective endocarditis in individuals with congenital heart disease is beyond the scope of this discussion, one principle is that fluid turbulence results in endothelial damage, whether the congenital lesion is valvular, as in congenital bicuspid aortic valves, or a ventricular septal defect. In patients with rheumatic valvular heart disease, infective endocarditis usually occurs in the mitral or aortic valves since these are the most commonly damaged heart valves. Studies with animal models suggest that turbulent flow may lead to injury and/or disruption of the vascular endothelium or endocardium. As a consequence, a matrix of platelets and fibrin is laid down to form a sterile vegetation. If significant bacteremia then occurs, and bacter- emia is common in humans, circulating microorganisms become 1 Source: (3). One of the most important factors determining whether bacteria infect sterile vegetation may be the concentration of bacteria circulat- ing through the bloodstream during bacteremia. Early studies also suggested that Gram-positive oral flora, such as viridans group strep- tococci, had a greater affinity for the vascular endothelium and en- docardium than did Gram-negative organisms. This correlated well with clinical observations that Gram-negative organisms frequently cause urinary tract infections, yet rarely cause infective endocarditis. However, investigators caution that understanding of the infective process is incomplete, and point to studies demonstrating that details of the intercellular interactions are species-dependent. This pattern changed in the latter half of that century, with an increase in the number of episodes of infective endocarditis associated with staphylococci, particularly in industrialized countries. Increasingly, Staphylococcus aureus and co- agulase-negative staphylococci were recovered from infective en- docarditis patients, probably because the patients had undergone medical or surgical procedures that required extended hospitaliza- tions. Similarly, yeast and fungi are also more common for rea- sons previously mentioned. In developing countries, the continuing predominance of viridans streptococci in patients with endocarditis has been attributed to the poor dental hygiene among children and adults in socially and economically disadvantaged populations. Since the clinical signs and symptoms commonly associ- ated with infective endocarditis are often nonspecific and overlap with many other illnesses, a diagnosis of infective endocarditis can be difficult using clinical observations alone. In 1994, to facilitate patient evaluation, more objective clinical criteria were published for assess- ing infective endocarditis (6). It is beyond the scope of this document to discuss the use of these criteria in detail. It thus important to confirm clinical suspicions of endocarditis with data from the microbiology laboratory. If there are no supporting microbiology laboratory facilities, or if existing ones are substandard, this makes a diagnosis of endocarditis especially difficult. A compli- cating factor is that patients with nonspecific symptoms at the onset of infective endocarditis are often given antibiotics or take antibiotics on their own. Consequently, even with microbiology laboratory facilities, it can be difficult to confirm a suspected infection. Laboratory studies for assisting the clinician can be divided into two major categories. First, the blood culture is a sine qua non for confirming a diagnosis of infective endocarditis. Since the bacteremia associated with en- docarditis is thought to be qualitatively continuous, there is no need for the clinician to wait for temperature elevations to obtain blood cultures. It is important to obtain more than a single blood culture (it has been proposed that three samples are sufficient) before any anti- biotic therapy is initiated. The volume of blood taken for laboratory culture evaluation can be important even in children. It is more difficult for the clinician to manage a patient with infective endocarditis if the underlying organism has not been identified. This is a problem in locations where there are no fully operational micro- biology laboratories. There is a consensus that, at least in local or regional referral hospitals, it is important that the laboratories be equipped for this important task. Other laboratory tests, such as measuring the erythrocyte sedimentation rate or levels of C-reactive protein or other acute-phase reactants, are often helpful for following the clinical course of patients, but are nonspecific measures of inflam- mation and are not pathognomonic of infective endocarditis. Haematuria, casts (or other signs of nephritis) and even small numbers of bacteria (especially staphylococci) in the urine are also helpful adjuncts in making a diagnosis of infective endocarditis. The technique of echocardiography is potentially the most useful “laboratory” examination in the diagnosis and management of 99 individuals with infective endocarditis. In adults, the resolution and sensitivity of echocardiography can be considerably improved by em- ploying transoesophageal echocardiography. It is beyond the scope of this document to completely discuss the advantages and disadvantages of this important diagnostic tool. While the identifica- tion of a vegetation can be most helpful in establishing the diagnosis, the failure to demonstrate the vegetation by echocardiography does not eliminate the disease from consideration.

Maintenance of anesthesia--potent inhalational agents (halothane/isoflurane/sevoflurane) purchase 100mg diclofenac amex, nitrous oxide generic 100 mg diclofenac visa, narcotics 100mg diclofenac otc, propofol. Lines and tubes Fluids in the Operative and Post-operative patient Pediatrician: “Why do they always get so much fluid? Major abdominal procedures can lead to losses of 15 cc/kg/hr in “third space” losses which must be replaced. Effect of Anesthesia on Fluid Balance: General anesthesia produces vasodilatation and some degree of myocardial contractility (usually overcome by sympathetic drive induced by the surgical stimulus), and thus a volume bolus may be needed. There is much discussion about which is better, what the cost/benefit ratio is, etc. You should at least be aware of which is which, and of the implications of choosing one over the other. Water flows along its concentration gradient, hence, water will leave the vascular space with the sodium, and less so with albumin. There is controversy (in the literature and with respect to individual patients) regarding when one needs to transfuse the patient. Remember that the function of red cells is to carry hemoglobin, carried by cardiac output. O2 transport capacity will thus be a factor of Hg level and the ability of the Hg to get to cells--which will be adversely affected by hyper viscosity. This does not, however address the issue of “tolerable” hematocrit--healthy patients will tolerate much lower hematocrits, and there is a risk involved in any transfusion. Component Therapy During a massive transfusion, coagulation factors and platelets will be reduced due to dilution, as they are not present in packed cells. If not replaced, bleeding will be greater, necessitating greater packed cell transfusion, etc. Extubation Criteria for extubation in the operating room are the same as those elsewhere--the patient must have an adequate airway, maintain oxygenation and ventilation (adequate strength as well as lung function), and have a neurologic status able to protect the airway and maintain adequate drive. Did the operation affect the airway (trachea, cords, pharynx) Breathing--Are the lungs normal or abnormal. Has there been enough fluid administered that there is concern about pulmonary edema? Did the operation involve the chest or abdomen in a way that will adversely affect the patient’s ability to breathe deeply? Neuro--Has anesthesia worn off to a degree that the patient can protect his airway and have adequate drive. Stridor--causes include trauma to trachea or cords, laryngeal edema, recurrent nerve damage, arytenoid dislocation. Treatment is as for viral croup--racemic epi, decadron, and re-intubation if necessary. If patient’s airway is compromised due to decreased mental status, a jaw thrust and nasal airway may temporize the problem. Generally patients will require some oxygen due to atelectasis, narcotics, and splinting. Remember that the In/Outs will not necessarily reflect the patient’s intravascular volume status (due to blood loss replacement, third space losses, evaporative losses). Of note, hypercarbia will lead to sympathetic nervous system activation, with impressive hypertension and tachycardia. Titration of drugs in the infant or ventilated/sedated/paralyzed patient requires assessment of vital signs. Common Procedures and Common Problems Spinal Fusion--Respiratory, Pain, Fluid Balance The post-operative course will be affected by the patient’s general medical history, degree of curvature, extent of the repair, and intraoperative course (fluid balance, blood loss, narcotics given). The most dreaded complication is paralysis, and patients who are cognitively able to follow commands will be submitted to a “wake-up test” intra-operatively, before closure of the wound. Potential post op problems include respiratory depression (excess analgesia), respiratory difficulty due to splinting (inadequate analgesia), pain control (difficult), and fluid balance. There is typically a fair bit of blood loss and there can be significant swelling of the involved tissues. The most important things to monitor are the status of the airway and continued bleeding. Tracheostomy--Airway, sedation, ventilation The most critical issues for the fresh trach is not losing it. Hence, patients who are “wild” should be adequately sedated, especially if they were trached because they were impossible to intubate. There are “stay sutures” which are at the base of the incision and can be held up to help provide a “tract” should the trach tube come out. Craniosynostosis--Blood Loss During craniectomy for craniosynostosis one or more of the sutures of the cranium are cut. You should be aware of whether the patient is syndromic or not (those with a “syndrome” typically have more sutures in need of repair, and might well have other problems), and the extent of the repair. Because of the large blood loss, they typically receive quite a bit of fluid intra-operatively as well as post-operatively. Each member of the team brings unique knowledge and perspective to the care of the patient and recognizing and integrating all members of the team in the ongoing care of the patient is essential in providing optimal care for these patients. The presence of trainees from medicine, nursing, respiratory therapy, or other disciplines adds to the size and complexity of the team caring for the patient, and the roles and responsibilities of these individuals must be explicitly acknowledged. Perioperative care encompasses both pre and post operative care of the patient with congenital heart disease. Although many infants and children with congenital heart defects are managed as outpatients until their repairs, some infants or older children with severely abnormal physiology require stabilization and critical care prior to surgery. Many of the basic principles of cardiac intensive care apply to both pre and post operative care and will be considered in this chapter. In addition to supportive care and stabilization, pre operative management includes thorough evaluation of the anatomy and physiology of the heart and the physiologic status of the patient as a whole so that appropriately planned and timed surgery can take place. Basic principles of pediatric critical medical and nursing care remain relevant in the pediatric congenital cardiac patient. Pediatric cardiac patients are cared for in specialized cardiac intensive care units and in multidisciplinary intensive care units. There is some data that institutions that perform more surgeries have improved outcomes (info here—based on surgeon, unit, hospital?? Regardless of the focus of the unit, a commitment to ongoing education and training, as well as a collaborative and supportive environment is essential. We feel strongly that a unit dedicated to the care of infants and children is best able to care for these patients (down on the adult units caring for kids). Oxygen delivery is therefore primarily dependent on systemic cardiac output, - 58 - hemoglobin concentration, and oxygen saturation. Stroke volume is in turn dependent on preload, afterload, and myocardial contractility. Both pulmonary blood flow (Qp) and systemic blood flow (Qs) are determined by these fundamental forces. In the patient with two ventricles, ventricular interdependence, or the affect of one ventricle on the other, may play a role in pulmonary or systemic blood flow.

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