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By: Robert Arntfield, MD

  • Assistant Professor of Medicine, Divisions of Emergency Medicine and Critical Care Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada

The main active ingredient in red yeast rice is monacolin K (lovastatin) gastritis supplements purchase 200 mg pyridium overnight delivery,338 which inhibits the enzyme that initiates the synthesis of cholesterol gastritis diet purchase pyridium 200mg mastercard. Omega-3 fatty acids gastritis symptoms ppt effective 200mg pyridium, isoflavones chronic gastritis diet mayo clinic 200mg pyridium free shipping, and plant sterols in red yeast rice are likely also responsible for its beneficial effects on lipids. Policosanol is a mixture of alcohols extracted from sugar cane, wheat germ, rice bran, or beeswax. One recent metaanalysis of natural interventions for abnormal and elevated lipids concluded that policosanol is more effective than plant sterols. In May of 2006, a randomized controlled trial studied four different doses of policosanol compared to each other and a placebo group. It may be that combining policosanol with other lipidlowering natural agents, and especially fish oils, will offer the most effect. A vast range of herbs have been used for decades, or even centuries, to treat heart and vascular system conditions. In addition, it diminishes the stiffness of arteries and decreases damaging plaque in blood vessels. Finally, exercise reduces the risk of arrhythmias, normalizes blood lipids, and increases insulin sensitivity. A recent study suggests that exercise and modest diet changes can decrease cholesterol and resultant atherosclerosis comparable to certain statins. Most important, by staying active with moderate levels of physical activity, we can prevent cardiovascular disease independent of other risk factors and improve our life expectancy. In one study, previously sedentary women performed 12 resistance exercises for one hour, three times per week. Another study noted that previously hypertensive adolescents who reduced their blood pressure by aerobic exercise were able to maintain blood pressure control by taking weight-lifting exercise after discontinuing aerobic exercise. Exercise recommendations have changed over the years and will likely continue to change with time. I recommend engaging in 40 to 60 minutes of moderate-intensity physical activity such as brisk walking on most days of the week or at a vigorous intensity for 20 minutes per day. Code and colleagues found that, in both men and women, the effects of exercise on blood pressure disappeared within weeks after the return to a sedentary lifestyle. Is an essential in rehabilitation after heart attack, stroke, or bypass surgery 10. Note that in men who seldom exercise, cardiac arrest is 56 times more likely during vigorous exercise than at rest. Walking program for heart patients:373 Weeks 1­2 3­4 5­6 7­8 9­10 Distance (miles) 1 1 1 1. Women should be encouraged to gradually increase their exercise and engage in an exercise program that is safe, convenient, and hopefully satisfying and even fun, at least at times. Many simple techniques can be effective in managing stress and reducing its baleful influence. Techniques such as deep-breathing exercises, biofeedback, transcendental meditation, yoga, progressive muscle relaxation, and hypnosis have all been shown to reduce stress and lower blood pressure. However, they constitute an important factor in a holistic program to lower blood pressure and treat and prevent heart disease. Natural (Bio-Identical) Hormone Replacement Therapy Whether a woman should go through the menopausal years without hormone therapy or To maintain the conditioning effect, exercise 20 to 30 minutes three to five times a week. If you stop exercise for more than two weeks, start again at a lower level and gradually build back up to your original program. If you have never exercised before, start with a few minutes each day and increase time gradually every week until you reach 30 minutes per day. For several decades, exercise has been advocated for the treatment of men who have had a heart attack or stroke. Recent encouraging results suggest that it should also be prescribed for women in similar situations. The decision is especially difficult when one considers the many unanswered questions about menopause, cardiovascular disease, and natural and conventional hormones. The method I follow is to systematically evaluate each woman with a thorough medical history, physical exam, and laboratory testing. The plan needs to change accordingly to carefully balance the benefits versus the risks of therapy. Both practitioner and patient need to be open-minded so that informed and appropriate decisions are reached. When it is appropriate, it behooves physicians to advise the use of the least objectionable options. Phytoestrogens and bioidentical hormone therapy are perhaps the most appropriate for some women, and I would assert, most women. However, only recently have natural progesterone creams been shown to have biological activity. Progesterone is synthesized from diosgenin or stigmasterol found in Mexican wild yams and soybeans. This hormone end product has come to be known as natural or bio-identical progesterone both because it is plant derived and, more important, because it is biochemically identical to the progesterone produced by the human ovary. Natural progesterone is biochemically different than progestin, which is commonly misstated as progesterone. For more information on the indications and effects of natural progesterone, please refer to Chapter 12. To date, unfortunately, very few studies have addressed the possible cardiovascular effects of these preparations in postmenopausal women. Perhaps what merits reflection here is that, despite its other undesirable effects, estrogen alone has the most favorable effect on lipids. At the lower doses, the decreases in systolic blood pressure were less significant. Studies demonstrate that synthetic progestins and natural progesterone have markedly different effects on the coronary vessels381 and on their smooth wall muscle cells. For more information on the use of natural progesterone alone or in combination with different estrogens in menopause, please refer to Chapter 12. Natural (Bio-Identical) Estrogens Natural estrogens are what we have come to call plant-derived bio-identical hormones. Mexican wild yam contains diosgenin and soy contains stigmasterol that can be converted into an estrogen biochemically identical to that produced by our ovaries. Bio-identical estradiol and estrone in a patented delivery system and in premanufactured dosages are available by prescription from a regular pharmacy. Bio-identical estradiol, estrone, and estriol can also be compounded in customized, individualized dosages of any strength, any combination, and in many different delivery systems including lozenges, sublingual tablets, creams, gels, capsules, and even injections. Theoretically, if we have a dose of a bioidentical estrogen that is equivalent in strength to the dose of the conventional estrogen, the cardiovascular benefit or risk should be the same. Nonetheless, any hormone therapy that is considered to be an alternative to the leading form of therapy (conjugated equine estrogens, i. Ten menopausal women, administered the natural estrogen/progesterone combination, experienced a decrease in total cholesterol. Estriol is used for a variety of treatments and is discussed in more detail in Chapter 12. However, two studies indicate positive effects of estriol administration on lipid profiles and cardiac function. When it comes to cardiovascular disease, I contend that ethically, practitioners using bio-identical hormone therapy must have the same benefit-risk conversation with patients as a conventional practitioner who prescribes the typical Premarin/ Provera would have. That said, in my opinion, there is enough evidence at this point that oral micronized progesterone is more cardiac friendly on lipids and coronary arteries than are the synthetic progestogens or progestin (such as Provera). Daily Supplementation Dandelion leaf capsules: 2 capsules daily Garlic: 1 capsule containing 4,000­5,000 mcg allicin, twice per day Coenzyme Q10: 100 mg per day Potassium: 99 mg­2. Differences would be related to the role of the first-pass hepatic effect, the hormone concentrations in the blood achieved by a given route, and the biologic activity of component ingredients. There is some evidence that transdermal 17 beta-estradiol does not increase the level of C-reactive protein, and also that it may be associated with lower risk of deep venous thrombosis than oral estrogen.

They persist over time gastritis diet example buy pyridium 200 mg lowest price, and except in the very young demand some kind of assessment gastritis gallbladder buy pyridium from india. A fibroadenoma is a rubbery gastritis diet purchase 200 mg pyridium otc, smooth biliary gastritis diet purchase pyridium 200mg otc, benign fibrous tumor common in younger women. Large cysts are more common in women aged 25 to 50-an age group when cancer just begins to appear. They are softer, usually squishier, and can be made to disappear by draining them through a needle in the office; unless they recur frequently, no further treatment is necessary. Recurrent large cysts have been shown to slightly increase cancer risk in some studies but not in others;3, 4 fibroadenomas do not. Given that this condition is not really a disease, a woman can direct her energies toward relieving symptoms and optimizing breast health, as well as increasing her motivation toward general health practices and self-care. Compromised liver function can lead to a state of estrogen dominance, contributing to texture and density changes in the breast. To assure that estrogens are being metabolized properly, it may be necessary to provide nutritional and herbal support for the liver. Digestion and elimination are fundamental factors involved in hormone-related health problems. Women having fewer than three bowel movements per week have a risk of fibrocystic breasts four to five times greater than women having at least one movement per day. Bacterial flora in the large intestine, such as Lactobacillus acidophilus, improve the transit time of bowel toxins, as well as improving the excretion and detoxification of estrogens. Women on a vegetarian diet excrete two to three times more detoxified estrogens than women on an omnivorous diet. Nutrition Epidemiological evidence supports a diet rich in whole fruits and vegetables in the prevention of fibrocystic breast conditions. A recent study demonstrated that a reduced risk of proliferative and atypical breast lesions was associated with consumption of fresh fruits and vegetables, whereas a small but significant reduction of risk was associated with soy consumption, possibly by decreasing cellular proliferation in the breast tissue. Even decaffeinated coffee has other methylxanthines, caffeine-like chemical compounds. John Minton, is probably the most well-known alternative treatment for fibrocystic breasts. Of the 20 uncomfortable women who followed his advice to stop all caffeine intake, 13 said their breasts felt better as a result. Virginia Ernster conducted the first randomized study of a larger number of women, in which for four months 158 women eliminated caffeine (coffee, tea, cola, and chocolate) from their diets as well as caffeinated medications (theophylline and theobromine). She found a significant reduction in clinically palpable breast findings in the abstaining group compared with the control group, although the absolute change in the breast lumps was quite minor and considered to be of little clinical significance. Caffeine (mg) 150 60­120 70 2­5 60­100 20 2­10 34 Food Milk chocolate (1 oz) Bittersweet chocolate (1 oz) Chocolate cake (1 slice) Caffeine (mg) 1­15 5­35 20­30 Over-the-Counter Drugs Anacin, Empirin, or Midol (2) Excedrin (2) NoDoz (2) Aqua-Ban (2) Dexatrim (1) Caffeine (mg) 64 130 200 200 200 In clinical practice, I always recommend avoiding caffeine for women with painful/lumpy breasts. Many women gain mild to dramatic results with this simple approach, and some women receive no benefit. A fair experiment would be to completely abstain for three months and observe any changes in the pain, swelling, and discomfort. A decrease in the nodularity will generally take longer, as long as eight months of complete abstention. How dietary fat affects the human breast is still controversial, although some research has looked at low-fat diets in women with fibrocystic breasts and at how low-fat diets affect the hormone levels in these women. Reducing the fat content of the diet to 16 percent of total calories (in contrast to the average American diet of 40 percent fat), while increasing complex carbohydrate consumption, has been shown to reduce the severity of premenstrual breast tenderness and swelling, as well as reduc- ing the actual breast swelling and nodularity in some women. However, a slight reduction in fat intake has repeatedly showed very little, if any, effect on breast problems, including breast cancer. A more rigorous approach to lowering the amount of fat in the diet is clearly needed. The simplest way to accomplish the necessary levels of fat reduction is to avoid animal fats in all forms; a vegan diet (vegetarian, without any animal products at all, including dairy or eggs) is naturally a very low-fat diet. Of course, vegetarians, and even strict vegans, can succumb to fat in other forms like french fries, potato chips, and other greasy fried foods. A vegan diet rich in whole grains, legumes, fruits, vegetables, seeds, nuts, olives, and seaweed that is enriched with oils for stir-frying and in salad dressings results in a diet that derives about 15 to 20 percent of its calories from fat. For more than 35 years, clinicians have used vitamin E in the medical management of benign breast disease. This practice was initially based on positive reports from small numbers of patients as far back as 1965 and from subsequent studies in 1971, 1978, and 1982. Two studies demonstrated that vitamin E is clinically useful in relieving pain and tenderness, whether cyclical or noncyclical. Since vitamin E in these dosages is completely safe to use, this is a simple and appropriate self-treatment method for a benign breast condition. The pain and tenderness of benign breast disease associated with cyclic mastalgia have been alleviated with evening primrose (Oenothera biennis) oil, the only one of the many essential fatty acids to be scientifically studied in relation to fibrocystic breasts. Evening primrose can be found in many parts of North American and is native in the North Temperate Zone, especially at high altitudes. The native peoples of North America, as well as the English and Pilgrims, were well aware of the healing properties of the leaves and bark as an astringent, nervine (an herb that affects the nerves and includes relaxants, tonics, and even stimulants), and sedative. It was often used for stomach and liver complaints, coughs, and female reproductive problems. The seeds were recommended as a coffee substitute in wartime and have a strong flavor similar to poppy seed oil. It is this seed oil and its essential fatty acid content that holds the most interest today in maintaining health and preventing disease. Evening primrose oil is rich in essential fatty acids-polyunsaturated fats that are as essential as vitamins and minerals for the maintenance of good health. Evening primrose oil also contains 11 percent oleic acid, 6 percent palmitic acid, and 2 percent stearic acid. These molecules are used in the regulation of inflammation, pain, blood pressure, fluid balance, and blood clotting. Research completed over the last 20 years has confirmed that supplementation with evening primrose oil has beneficial effects in numerous diseases and conditions. Other conditions for which it may provide benefit include menopause and pregnancy. The pain and tenderness of benign breast disease associated with premenstrual breast pain and fibrocystic breasts has been alleviated with evening primrose oil in more than one scientific study. In 1985, when 291 women took three grams per day of evening primrose oil for three to six months, almost half of the 92 women with cyclic breast pain experienced improvement compared with one-fifth of the patients who received the placebo. For those women who experienced breast pain throughout the month, 27 percent (just over one-fourth of the 33 women) responded positively to the evening primrose oil, compared to 9 percent on the placebo. After three months, pain and tenderness were significantly reduced in both cyclical and noncyclical groups, while the women who took the placebo did not significantly improve. This may also have long-term implications for prevention of breast diseases such as breast cancer. Although symptom relief can be achieved through the use of evening primrose oil, it should not be relied on to actually reduce the number of developing cysts. Other omega-6 fatty acids that may have beneficial effects but have not been studied in relation to fibrocystic breasts are flaxseed oil, black currant oil, and borage oil. That would mean instead of the 6 capules of evening primrose oil it would take to achieve the 3,000 mg of evening primrose oil that was used in the study, you could conceivably use at half as many capsules of borage oil. Basic science research supports the use of vitamin A by demonstrating the presence of specific retinoid receptors in breast tissue that can modulate our genetic predisposition, thereby decreasing the risk for both benign and malignant breast changes. Although the potential toxicity of vitamin A in doses this high makes it an impractical approach to fibrocystic breast disease, it is possible that betacarotene could be substituted, since it has a similar activity without the side effects of vitamin A, or a diet high in yellow and orange fruits and vegetables. It has been known for a long time that for the thyroid gland to secrete thyroxine (its hormone), it requires iodine. Prescription thyroid hormone replacement with low or even normal thyroid function may result in improvement of fibrocystic breasts. The only areas of the breast in which iodine can be found are in the terminal and interlobular duct cells, which are also the areas primarily involved in cystic changes. Without iodine, the breast tissue becomes more sensitive to estrogenic stimulation, which in turn produces microcysts high in potassium. The potassium is believed to be an irritant that produces fibrosis and eventually cyst isolation. Four types of iodine have been studied in the treatment of fibrocystic breasts, only one of which has been truly effective and free of side effects on the thyroid gland.

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Treatment Immunosuppressant agents form the gold standard treatment for non-infectious uveitis gastritis symptoms nausea order cheapest pyridium and pyridium. Most patients with non- infectious uveitis are treated with locally applied immunosuppressants gastritis symptoms patient.co.uk buy pyridium overnight delivery. In anterior uveitis gastritis symptoms baby purchase 200mg pyridium mastercard, topical steroids drops comprise the initial treatment gastritis diet and yogurt purchase cheap pyridium line, but are usually combined with cycloplegic drops for pain relief and prevention of posterior iris adhesions. If vision is severely impaired, the initial treatment of choice is intravenous methylprednisolone (1 g, daily) for 1 to 5 days. Before the era of biologicals, intravenous cyclophosphamide could be used as an alternative for steroids in severe sight-threatening uveitis, although presently this treatment is reserved for refractive cases. In cases of chronic refractory uveitis, it might even be necessary to continue maintenance therapy for Distributed under creative commons license 4. The ophthalmologist will refer patients with signs and symptoms of sarcoidosis to another medical specialist in order to diagnose and subsequently treat the extra-ocular sarcoidosis. This is important as sarcoidosis can cause several severe health problems in absence of a clear clinical phenotype, including impaired lung function, increased liver enzymes. The advent of biologicals has presented a new class of drugs that can be used to treat non-infectious uveitis [23]. Infliximab and adalimumab in particular are associated with an excellent and durable therapeutic efficacy in uveitis treatment. Infliximab is administered intravenously every two months and adalimumab is given subcutaneously every two weeks. In cases of unilateral uveitis or when systemic medication is not well-tolerated, there are currently several options for intraocular treatment. Over the years several steroid implants have been introduced, which are composed of a slow-release system, enabling a therapeutic effect that lasts from 3 months to 3 years [27,28]. Another possibility, which is also used for the treatment of ocular lymphoma, is intravitreal injection of methotrexate. Conclusions Since many disorders can cause uveitis, patients with uveitis are often managed by a team of medical subspecialists. The management of severe cases of uveitis should be coordinated by an experienced multidisciplinary team comprising both ophthalmologists and other medical specialists. Nevertheless, these drugs have been shown to translate to considerable improvements in the treatment of certain uveitis patients. Ophthalmological diagnostic screening A Dutch national guideline for the diagnosis and treatment of uveitis has been formulated on the basis of the knowledge detailed above [29]. In clinical practice, the ophthalmologist usually initiates the first round of diagnostic screening, except in case of a first episode of mild anterior uveitis. The role of other medical subspecialties Following initial screening by an ophthalmologist, patients are referred to another medical specialist for further evaluation and to either treat the underlying cause of uveitis or assist in the initiation of the appropriate immunosuppressive or antibiotic treatment. The only exception to this rule is a first case of mild anterior uveitis, which warrants a less aggressive approach (Figure 5). The clinical presentation of the uveitis primarily determines the referral strategy. Patients that receive long-term immunosuppressive therapy are often monitored by internists or other medical subspecialists. Depending on the cause and severity of uveitis, the management of uveitis can be coordinated in a multidisciplinary team meeting in order to rapidly start these patients on the appropriate therapeutic regimen. When a non-ophthalmologist encounters a patient with a Distributed under creative commons license 4. Incidence and prevalence of uveitis in Northern California; the Northern California Epidemiology of Uveitis Study. Infectious uveitis in immunocompromised patients and the diagnostic value of polymerase chain reaction and GoldmannWitmer coefficient in aqueous analysis. Polymerase chain reaction and Goldmann-Witmer coefficient analysis are complimentary for the diagnosis of infectious uveitis. Necrotizing and nonnecrotizing variants of herpetic uveitis with posterior segment involvement. Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients. Comparison of rubella virus- and herpes virus-associated anterior uveitis: clinical manifestations and visual prognosis. Epidemiologic relationship between fuchs heterochromic iridocyclitis and the United States rubella vaccination program. A systematic review of the incidence and prevalence of autoimmune disease in multiple sclerosis. Mult Scler 2015(2): 94-99 99 [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] 2015; 21: 282-293. Differential efficacy of tumor necrosis factor inhibition in the management of inflammatory eye disease and associated rheumatic disease. Randomized comparison of systemic antiinflammatory therapy versus fluocinolone acetonide implant for intermediate, posterior, and panuveitis: the multicenter uveitis steroid treatment trial. Treatment with repeat dexamethasone implants results in long-term disease control in eyes with noninfectious uveitis. Vincent Road Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739 +91-484-2395740 e-mail: kochi@jaypeebrothers. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher. This book has been published in good faith that the material provided by authors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. For a postgraduate in ophthalmology, a comprehensive book on Basic Sciences is an absolute need from examination point of view. This book does not claim to be a complete treatise in Basic Sciences, but the aim is to guide the postgraduates to prepare the Basic Sciences for the theory examination. I must acknowledge and thank my colleagues Prof (Dr) K Vasantha, Prof (Dr) Leela, Prof (Dr) Mythili and Dr Sundar for their hard and sincere efforts and also their contributions. Finally, I thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, for having taken the sincere efforts to publish this book. Routes of Administration of Drugs for Ocular Conditions Anti-inflammatory Agents Antiallergic Drugs Drugs Used for Dry Eyes and Corneal Edema Antibiotics Antivirals Antifungal Agents Antihypertensives Parasympathomimetics, Mydriatics and Mydriolytics 231 233 237 244 246 249 255 258 260 264 X 24. Microbiology 335 337 Index 429 1 the Eyeball the eyeballs, which are responsible for vision the most precious sensation, is well protected by the bony orbit. The eyeballs are situated in the anterior part of the orbit closer to the roof and lateral wall than the floor and the medial wall. When a line is drawn from the superior orbital margin down to the inferior margin it will just touch or will be very close to the cornea. Hence, any injury to the eye is more common from the lateral side causing rupture globe on the upper medial part of the eye. The anterior part, which is formed by the cornea is more curved with a radius of curvature of 8 mm or even less. Since the cornea is more curved the anteroposterior diameter is around 24 mm while the horizontal diameter is about 23. The eyeball has three layers: the outer tough sclera with the cornea anteriorly, the vascular choroid forms the middle layer and the neurosensory retina forms the inner most layer. The lids protect the eyes from injuries as well as control the amount of light entering the eyes. The lids spread the tear fluid uniformly over the eyeball by blinking there by keeping the surface of the eye moist. The excessive secretion of tears is also pumped out of the palpebral fissure by the lids. Correct eyelid position and function are needed for spreading the tear fluid uniformly over the conjunctiva and the cornea.

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Pleuritis gastritis what not to eat quality 200mg pyridium, peritonitis and pericarditis also be seen in some cats and dogs gastritis unspecified icd 9 code best pyridium 200 mg, but the serosa is usually thickened by granulation tissue rather than forming nodules gastritis diet purchase pyridium visa. Some other lesions that may be found in tuberculosis include straw-colored or serohemorrhagic fluid in the body cavities or pericardium; ulcerative lesions in the trachea gastritis diet order pyridium from india, bronchi or intestines; osteomyelitis; and various abnormalities in the joints, including proliferative lesions and joint capsule mineralization. Small nodules are usually not caseated; larger nodules may be caseous but do not usually mineralize. Diagnostic Tests Tuberculosis can be diagnosed by detecting either the causative organisms or the immune responses to these organisms. Animals that react in either type of test are generally treated as having an active infection. In some species, diagnostic tests may be supplemented with x-rays or other imaging techniques to visualize abnormalities in the internal organs. Tuberculin, a mixture of bacterial proteins, is injected intradermally and the site is examined 48-96 hours later for an inflammatory swelling (delayed hypersensitivity reaction). The tuberculin test is also used in other animals, but it must be validated in each species, and the injection site can differ. Tuberculin tests have also been evaluated and/ or used in goats, water buffalo, guinea pigs and a limited number of wildlife hosts. There is relatively little research on these tests in sheep, and some authors report that false negatives are common unless the animal has extensive lesions. They are considered to be unreliable, due to inadequate sensitivity and/or specificity, in cats, dogs, horses, European badgers and brush-tailed opossums. Practical considerations, including the need to recapture the animal to read the test, can also preclude their use. They have also been combined with skin tests to increase sensitivity or specificity. As of 2019, these tests have been used or evaluated in a limited number of species including goats, sheep, South American camelids, cats, badgers and lions. They were also employed, in conjunction with serology, during an outbreak in dogs. Samples for this test must be transported to the laboratory promptly, as it must be started within 24-30 hours of blood collection. However, they have been used to help diagnose tuberculosis in South American camelids, farmed cervids, dogs, elephants, and a number of captive or free-living wildlife infected with M. At one zoo, gradually increasing antibody titers preceded positive tuberculin skin tests in a M. Serology may occasionally be useful in cattle or goats in the late stages of tuberculosis. There are a few reports of these tests being used to monitor responses to treatment. Cross reactions to other bacteria, especially environmental mycobacteria, can complicate test interpretation. Tuberculin skin tests can boost serological responses in deer and South American camelids, and combining these tests can reveal infected animals that do not respond in the skin test. An attempt to use it in elephants resulted in a high rate of false positive reactions. Trunk washes to collect sputum are a routine diagnostic test in elephants, as there are few other © 2003-2019 antemortem tests in this species. More often, tuberculosis is confirmed in tissue samples from affected organs, taken at necropsy. In cattle with no visible lesions, the recommended minimum sample is pooled lymph nodes from the head and thorax. A recent study found that, in cattle with no visible lesions that were infected by ingestion, M. A presumptive diagnosis can be made by histopathology and/or the demonstration of acid-fast bacilli in smears from tissues, exudates or body fluids. Direct smears for microscopy can be stained with ZiehlNeelsen stain, a fluorescent acid-fast stain. While colonies may occasionally appear as early as 2 weeks, the median time on solid media is 4-5 weeks, and some samples may require up to 12 weeks or longer. Because these slowgrowing organisms can be overgrown by contaminants, samples for culture should be collected as aseptically as possible. If necessary, culture can incorporate a decontamination step, where the samples are treated with a toxic agent to which members of the M. Biochemical methods are slow and labor-intensive and may occasionally give ambiguous results, and molecular methods are generally preferred if they are available. It has the advantage of speed, and can also be helpful when organisms are difficult to grow. In endemic areas, barrier nursing precautions and tuberculocidal disinfectants should be considered in veterinary hospitals when animals have signs consistent with tuberculosis. Control programs are usually targeted at bovine tuberculosis in cattle, but some programs may include M. In these programs, animals are tested periodically with the tuberculin skin test and/or other assays. If an infected herd is found, the reactors are removed and the herd is quarantined until all animals test negative. Reactors are generally slaughtered, but some countries may employ test-and-segregation programs at first, and later switch to test-and-slaughter. Once eradication is nearly complete, slaughter surveillance, with tracing of infected animals, may be a more efficient use of resources. However, it is relatively insensitive, and can miss infected animals with few or no visible lesions. Transmission from these animals to livestock can be reduced with biosecurity measures such as wildlife barriers around feed storage areas, or solid metal barriers and gates to exclude badgers from cattle pens. Some countries have also established control programs targeted at the principal maintenance host(s). Culling may decrease their population density below the level needed to sustain transmission. However, each situation must be assessed individually, as culling may have unanticipated effects if it encourages infected animals to disperse. Capture and testing programs, with the release of uninfected animals, have sometimes been used in badgers and African buffalo. Some control programs include bans on feeding deer and elk, to reduce transmission between congregating animals and discourage transmission on fomites. Treatment Antibiotics have been used to treat some animals with tuberculosis, especially pets and zoo animals. However, the possibility of clinical improvement without bacteriological cure must be kept in mind. Some animals that responded initially later relapsed, especially with inadequate treatment. The risk of shedding organisms, hazards to humans (especially if the respiratory tract is infected or there are draining lesions), and potential for the development of drug resistance make treatment controversial. Treatments for animals are usually patterned after successful protocols used in humans, and employ two or more drugs, given simultaneously for months. When selecting antibiotics, it should be kept in mind that, except in rare cases, M. One protocol for cats, which are unusually sensitive to some of the commonly used tuberculocidal drugs, combines rifampicin, a fourth generation fluoroquinolone such as pradofloxacin, and clarithromycin or azithromycin. Surgery is occasionally used to remove small masses, treat ocular tuberculosis. Drug treatment alone seems to have poor results in cats that have significant osteomyelitis or joint involvement. Control Disease reporting Veterinarians who suspect an animal is infected with a member of the M. Prevention Sanitation and disinfection, open air housing rather than confinement, and avoidance of crowding might reduce the spread of tuberculosis within a herd.

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