By G. Frillock. Northwestern Oklahoma State University. 2018.

Tricuspid regurgitation commonly co-exists and is more often secondary to right ventricular dilatation discount dulcolax 5 mg on-line, than to primary rheumatic involvement generic dulcolax 5mg overnight delivery. Digoxin is the preferred agent to control ventricular rate; beta-blockers and rate-slowing calcium channel 59 antagonists have negative inotropic effects that could be deleterious in this setting. Nutritional efforts to protect against hypoalbuminemia and the use of graduated compression stockings are also helpful. Mitral regurgitation The volume load of chronic mitral regurgitation can be well tolerated for several years. Indeed, the favourable loading conditions may ob- scure the recognition of left ventricular contractile dysfunction until relatively late in the natural history. Symptoms and/or signs of left ventricular systolic dysfunction (defined by an ejection fraction <0. The long-term results of mitral valve surgery are influenced by age, the severity of symptoms, coexistent coronary artery disease, pre- operative left ventricular function, the type of surgery (repair vs. A few small-scale studies have suggested that patients with rheu- matic (fixed orifice) mitral regurgitation might actually experience haemodynamic worsening following exposure to vasodilators (25– 27). These agents, particularly angiotensin converting enzyme inhibi- tors, are certainly indicated for the treatment of coexistent systemic hypertension or established left ventricular systolic dysfunction, whether or not symptoms are present. Beta-blockers (metoprolol, bisoprolol, carvedilol) and digoxin can be used to manage chronic heart failure owing to left ventricular systolic dysfunction, as currently recommended by consensus guidelines (28). Atrial fibrillation is managed according to the principles enumerated above for mitral stenosis. In chronic, severe mitral regurgitation, the left atrium can dilate to massive proportions (“giant” left atrium), thus hindering the chances for successful restoration and maintenance of sinus rhythm. Pulmonary hypertension and failure of the right side of the heart can occur, but are usually less prominent features of the natural history of mitral regurgitation than they are with mitral stenosis. One lesion may predominate, or the components may be more closely balanced, creating a hybrid natural history. The combined use of diuretics and vasodilators in symptomatic patients may prove challenging, given the more difficult- to-predict effects on filling pressures and systemic perfusion, although the former agents are well tolerated in patients with pulmonary con- gestion. Aortic stenosis The well-known natural history of aortic stenosis has long dictated that surgery be undertaken once symptoms appear. Indeed, survival without valve replacement after the onset of angina, syncope, or heart failure is generally measured at five, three, and two years, respectively 2 (30). Once left ventricular systolic dysfunction intervenes, digoxin can be added; beta-blockers and other drugs with negative inotropic effects should be avoided. Angiotensin converting enzyme inhibitors must also be given with great care in this setting, but may on occasion be helpful in controlling or ameliorating symptoms. Patients with heart failure and aortic stenosis with “low gradient/low output” should undergo referral and additional testing to determine if the depressed left ventricular func- tion is due to severe, uncorrected aortic stenosis (afterload mismatch) or to a primary cardiomyopathy (31). Asymptomatic patients with aortic stenosis may require treatment for other, acquired cardiovascular diseases, such as hypertension and coronary artery disease. In the presence of normal left ventricular systolic function, standard doses of angiotensin converting enzyme inhibitors, beta-blockers, and long-acting nitrate preparations are usually well tolerated, though caution is always advised when 61 instituting these medications. Several recent studies in patients with degenerative, calcific aortic stenosis have identified smoking, hyperlipidaemia, elevated creati- nine, and hypocalcaemia as risk factors for the progression of disease (32–34). Aggressive prevention strategies would seem appropriate for patients with rheumatic disease as well, if only to reduce the incidence of coronary heart disease events, although specific data are lacking. Physical activity need not be restricted in patients with mild aortic 2 stenosis (valve area >1. Severe aortic stenosis usually mandates a reduction in physical activities to low levels (9). Aortic regurgitation Patients with chronic, severe aortic regurgitation usually enjoy a long, yet variable compensated phase characterized by an increase in left ventricular end-diastolic volume, an increase in chamber compliance, and a combination of both eccentric and concentric hypertrophy. Preload reserve is maintained, ejection performance remains normal, and the enormous increase in stroke volume allows preservation of forward output (9). In contrast to the haemodynamic state associated with mitral regurgitation, however, left ventricular afterload progres- sively increases. Vasodilators can favorably alter these load- ing conditions and may extend the compensated phase of aortic regur- gitation prior to the development of symptoms or left ventricular systolic dysfunction (defined as a subnormal resting ejection fraction) that would prompt valve replacement. Preoperative left ventricular function is the most important predictor of postoperative survival. The natural history of asymptomatic patients with normal systolic function has been well characterized. The rate of progression to symptoms and/or systolic dysfunction has been estimated at less than 6% per year. Asymptomatic patients with left ventricular dysfunction, how- ever, develop symptoms (angina, heart failure) at a rate of >25% per year, and symptomatic patients with severe aortic regurgitation have an expected mortality that exceeds 10% per year (9).

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To settings discount dulcolax 5 mg amex, diagnostic capacity cannot match the current date 5mg dulcolax with amex, a cumulative total of 58 countries have confirmed needs. Treatment success was lished for 2015 – the diagnosis and treatment of 80% of documented in 60% of patients overall. Anti-Tuberculosis Drug Resistance Surveillance, data Te Supranational Reference Laboratory Network1 on drug resistance have been systematically collected expanded to include three additional laboratories in and analysed from 114 countries worldwide (59% of all 2007–2009 and now comprises 28 laboratories world- countries of the world). Compared with lines: Bangladesh, Belarus, Kyrgyzstan, Pakistan and the 4th report on anti-tuberculosis drug resistance Nigeria. Updated data on trends are available Of 114 countries that provided information between from 37 countries. Te Russian B continuous surveillance data and was therefore not Federation reported both Class A and Class B subna- included in Map 4. Tese high propor- countries that have conducted continuous surveillance tions explain in part the slow progress made in Eastern since the time of publication of the 4th report on anti- European and Central Asian countries in reaching the tuberculosis drug resistance in 2008 (6). Countries not meeting the mortality rates by 2015 compared with their levels of criteria for reporting Class A or Class B data are not in- 1990 (8). Within Class categories, countries are stratified by status as high-income countries or non 1. Since the publication in 2008 of the 4th report on Less than one fourth of all countries (22%), the vast anti-tuberculosis drug resistance (6), five countries majority being high-income countries, have continuous have completed drug resistance surveys and reported surveillance systems in place. Tajikistan’s subnational sur- come countries report Class A continuous surveillance vey of its capital Dushanbe and neighbouring Rudaki data. Te findings of the of South Africa) and the South-East Asia Region, has first nationwide drug resistance survey conducted in continuous drug resistance surveillance in place. How- 2007 in China are among those presented in this report ever, the work performed by the Damien Foundation (Table 3 and Box 1). Four middle-income countries (Latvia, nia, Benin, Bolivia, Bulgaria, Ecuador, Egypt, Lesotho, Lithuania, Montenegro and Serbia) and 12 of the 83 Mexico, Nigeria, Poland, Swaziland, Togo and Zambia) federal subjects of the Russian Federation report Class and 5 (Belarus, Brazil, India, Indonesia, and Philip- A continuous surveillance data. Five of these countries have never conducted khstan, the Russian Federation, Georgia, the Republic surveys before (Albania, Bulgaria, Belarus, Nigeria and of Moldova and South Africa – have surveillance sys- Togo). Results from these surveys will be available in tems in place that with additional efforts could soon 2010–2011 and will greatly contribute to an under- provide high-quality nationwide drug resistance data. When properly risk factor for drug resistance, as shown from surveys designed, implemented and with results correctly ana- and surveillance systems worldwide (6). Bangladesh, however, has reported important estimated global odds ratio combining all available data is also presented (◊). Sfqvcmjd Ftupojb Hfpshjb Hfsnboz Ivohbsz Jsfmboe Jtsbfm Jubmz Mbuwjb Mjuivbojb Ofuifsmboet Opsxbz Pnbo Qpsuvhbm Sfqvcmjd! An estimated global odds ratio combining all available data is also presented (◊). The more data that are available from each country, the bigger the square representing the point estimate of the odds ratio and the shorter the line across the square representing the confdence interval. An estimated global ularly in previous years) have led to high death rates in odds ratio combining all available data is also presented (◊). Tis may be countries providing Class B continuous surveillance a result of lack of testing of patients or of incomplete data. Significant decreases in the propor- conducting continuous surveillance and surveys. By increasing the number of but do not document deaths in cases of treatment de- countries providing up-to-date nationally representa- fault and failure. Tis is particularly a priority in Africa (Box 3), treatment with second-line drugs. Among these countries, 12 have conducted a nationwide survey since 2000; 10 have conducted a survey only at a subnational level (state, province, or district) or have not repeated it in the past decade, or both (Map 2). Only one country (South Africa) collects routine surveillance data, although the quality of the data is Class B (Annex 4 and Map 5). Slow technology transfer, compounded by the advanced stage of developing their plans at the time of need for modern and expensive laboratory infrastruc- publication of this report. It will promote new and rapid diagnos- Te laboratory plays a central role in patient care and tic technologies within appropriate laboratory services surveillance, and thus provision of quality-assured through 2013 to ensure that new tools are properly in- services is critical. Technology transfer has started in five countries, countries had an officially recognized national refer- paving the way for accelerated patient diagnosis and ence laboratory (Table 7). Te prog- Te availability of facilities to conduct culture and ress being made in Ethiopia is described in Box 4. In 24 of these 27 countries, at least one laboratory had capacity to per- form culture for M. Europe reported testing more than 1% of new cases, Cohorts from quality-assured sites registered higher 10 of which had a coverage ranging from 28% to 77%. Patient treatment is individualized and hospital- based until sputum converts to culture negative.

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