", womens health practice."

By: Cynthia P. Koh-Knox, PharmD

  • Clinical Associate Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana


Microscopy of the tumour shows lobules of monomorphic seminoma cells separated by delicate fibrous stroma containing lymphocytic infiltration women's health questions pregnancy symptoms . The seminoma cells generally lie in cords breast cancer on ultrasound , Histologically women's health center hilo , the distinctive features are as under: sheets or columns forming lobules breast cancer 993 . The tumour cells vary considerably in seminoma, the tumour cells are fairly uniform in size with size from lymphocyte-like to huge mononucleate or clear cytoplasm and well-defined cell borders. Majority of the tumour cells are, plasm contains variable amount of glycogen that stains however, of intermediate size. The nuclei of intermediate located, large, hyperchromatic and usually contain 1-2 and large cells have filamentous pattern. The stroma lacks lymphocytic and granulo seminomas have increased mitotic activity and have matous reaction seen in classic seminoma. The stroma of seminoma is delicate fibrous compared and better than classic seminoma since the tumour tissue which divides the tumour into lobules. The tumour is shows a characteristic lymphocytic infiltration, indicative radiosensitive. About 20% of the tumours show granulomatous reaction in the Embryonal Carcinoma stroma. Pure embryonal carcinoma constitutes 30% of germ cell the prognosis of classic seminoma is better than other tumours but areas of embryonal carcinoma are present in germ cell tumours. These tumours are more common Natural history of anaplastic seminoma, however, is in 2nd to 3rd decades of life. It distorts Spermatocytic seminoma is both clinically and the contour of the testis as it frequently invades the tunica morphologically a distinctive tumour from classic seminoma and the epididymis. It is an uncommon tumour having an incidence Microscopically, the following features are seen: of about 5% of all germ cell tumours. Grossly, spermatocytic cells having large size, indistinct cell borders, amphophilic seminoma is homogeneous, larger, softer and more cytoplasm and prominent hyperchromatic nuclei showing yellowish and gelatinous than the classic seminoma. Polyembryoma Embryonal carcinoma is more aggressive and less Polyembryoma is defined as a tumour composed predo radiosensitive than seminoma. Polyembryoma is extremely rare but embryoid (Synonyms: Endodermal Sinus Tumour, bodies may be present with embryonal carcinoma and Orchioblastoma, Infantile Embryonal Carcinoma) teratoma. This characteristic tumour is the most common testicular tumour of infants and young children upto the age of 4 years. Choriocarcinoma In adults, however, yolk sac tumour in pure form is rare but Pure choriocarcinoma is a highly malignant tumour compo may be present as the major component in 40% of germ cell sed of elements consisting of syncytiotrophoblast and tumours. However, pure form is extremely rare and occurs more often in combination with other germ cell tumours. The primary generally soft, yellow-white, mucoid with areas of necrosis tumour is usually small and the patient may manifest initially and haemorrhages. Grossly, the tumour is reticular network, papillary, tubular and solid arrange usually small and may appear as a soft, haemorrhagic and ment. The tumour cells are flattened to cuboid epithelial cells Microscopically, the characteristic feature is the with clear vacuolated cytoplasm. The tumour cells may form distinctive perivascular and cytotrophoblast without formation of definite structures resembling the yolk sac or endodermal sinuses placental-type villi. Cytotrophoblastic cells are polyhedral cells which are more regular and have clear or eosinophilic cytoplasm with hyperchromatic nuclei. Teratoma Teratomas are complex tumours composed of tissues derived from more than one of the three germ cell layers—endoderm, mesoderm and ectoderm. Testicular teratomas are more common in infants and children and constitute about 40% of testicular tumours in infants, whereas in adults they comprise 5% of all germ cell tumours. However, teratomas are found in combination with other germ cell tumours (most commonly with embryonal carcinoma) in about 45% of mixed germ cell tumours. Sectioned surface shows replacement of the entire testis by variegated mass having grey-white solid areas, cystic areas, honey-combed areas and foci of cartilage and bone. Grossly, most teratomas are large, grey-white masses infants and children and has favourable prognosis. Cut surface shows However, similar mature and benign-appearing tumour characteristic variegated appearance—grey-white solid in adults is invariably associated with small hidden foci areas, cystic and honey-combed areas, and foci of cartilage of immature elements so that their clinical course in adults and bone (Fig. It is believed that all testicular teratomas in the ovaries are rare in testicular teratomas. Microscopically, the three categories of teratomas show As mentioned above, dermoid cysts similar to those different appearances: of the ovary are rare in the testis. Immature teratoma is composed composed of disorderly mixture of a variety of well of incompletely differentiated and primitive or embryonic differentiated structures such as cartilage, smooth muscle, tissues along with some mature elements (Fig. This type of mature or differentiated abortive eye, intestinal and respiratory tissue elements etc. This is an Sertoli Cell Tumours (Androblastoma) 713 extremely rare form of teratoma in which one or more of Sertoli cell tumours correspond to arrhenoblastoma of the the tissue elements show malignant transformation. They may occur at all ages but are more frequent in malignant change resembles morphologically with typical infants and children. These tumours may elaborate oestrogen malignancies in other organs and tissues and commonly or androgen and may account for gynaecomastia in an adult, includes rhabdomyosarcoma, squamous cell carcinoma or precocious sexual development in a child. Grossly, the tumour is Mixed Germ Cell Tumours fairly large, firm, round, and well circumscribed. Cut About 60% of germ cell tumours have more than one of the surface of the tumour is yellowish or yellow-grey. Interestingly, Majority of Sertoli cell tumours are benign but about 10% metastases of the mixed germ cell tumours may not exactly may metastasise to regional lymph nodes. Granulosa Cell Tumour the most common combinations of mixed germ cell this is an extremely rare tumour in the testis and resembles tumours are as under: morphologically with its ovarian counterpart (Chapter 24). An example of combination of both germ cells and sex cord stromal components is gonadoblastoma. The primitive mesenchyme Dysgenetic gonads and undescended testis are predisposed which forms the specialised stroma of gonads in either sex to develop such combined proliferations of germ cells and gives rise to theca, granulosa and lutein cells in the female, sex cord-stromal elements. Most of the cell of origin of primitive mesenchyme is identical, Sertoli gonadoblastomas secrete androgen and therefore produce and interstitial Leydig cell tumours may occur in the ovaries virilisation in female phenotype. A few, however, secrete (in addition to theca cell, granulosa cell and lutein cell oestrogen. Likewise, the latter three tumours may occur in the testis (in addition to Sertoli cell and Leydig cell tumours). Call-Exner bodies of Leydig (Interstitial) Cell Tumour a granulosa cell tumour may be present. They may occur Prognosis largely depends upon the malignant potential at any age but are more frequent in the age group of 20 to 50 of the type of germ cell components included. Characteristically, these cells secrete androgen, or both androgen and oestrogen, and rarely corticosteroids. Grossly, the tumour Malignant lymphomas comprises 5% of testicular malignan appears as a small, well-demarcated and lobulated cies and is the most common testicular tumour in the elderly. Histologically, the tumour is composed of sheets and cords of normal-looking Leydig cells. These cells contain Rare Tumours abundant eosinophilic cytoplasm and Reinke’s crystals In addition to the testicular tumours described above, some and a small central nucleus. Only about 10% cytoma, leukaemic infiltration, carcinoid tumour, may invade and metastasise. The structure of penis consists of 3 masses of erectile tissue— two corpora cavernosa, one on Balanitis Xerotica Obliterans each side dorsally, and the corpus spongiosum ventrally Balanitis xerotica obliterans is a white atrophic lesion on the through which the urethra passes. The expanded free end of glans penis and the prepuce and is a counterpart of the lichen the corpus spongiosum forms the glans. In the prostatic part, it is lined by transitional epithelium, but elsewhere it is lined by columnar epithelium Benign and malignant tumours as well as certain premalig except near its orifice where stratified squamous epithelium nant lesions may occur on the penis. The tumour may occur singly, or there may be anomaly whereas acquired phimosis may result from conglomerated papillomas. A more extensive, solitary, inflammation, trauma or oedema leading to narrowing of exophytic and cauliflower-like warty mass is termed giant preputial opening.

Published laundry regulations must be followed if the facility does its own laundry breast cancer 77 year old . In addition menstrual discomfort , carts shall be cleaned and disinfected before being 304 used to menopause 2 periods in one month transport clean or sterile linen women's health center towson md . If their use is unavoidable, ensure that they are properly 304 designed, maintained, cleaned, disinfected, and used in a manner that minimizes dispersion 92,218 of aerosols from contaminated laundry. Ensure that laundry bags are securely bagged and tightly closed before placing the filled bag 3,92 into the chute. Special handling of linen for clients/patients/residents on Additional Precautions is not 92,218,358 routinely required. Cloth linen bags should washed after each use and can be washed in the 3 same cycle as the linen contained in them. Laundered items should be taken out of the washer as soon 92,347 as feasible to reduce the risk of contaminating the washer and formation of biofilm. There should be 3,92 posted instructions on washing and drying patient/resident laundry. Using a disinfectant (such as bleach) may not offer additional advantage when soiling is at 347 low levels. However, a disinfectant can be used to enhance the overall disinfection of the laundry process when there is heavy soiling of the items to be laundered, or when resettling of microorganisms 347 in the wash or rinse water onto the laundered items is a concern. If a closed cart system is used, storage of clean linen carts in an 80,81 alcove is permitted if it is out of the path of normal traffic and under staff control. Disposable gloves are recommended and these should be sufficiently long to 304,322 cover the forearm and be tear-resistant. If reusable personal protective equipment is used, 304,322 it shall be cleaned daily at a minimum and designated to the individual. Any sharps found in linen shall be reported to management and documented to prevent future 304 incidents from happening. There must be policies and procedures to ensure that clean laundry is transported and stored in a manner that will ensure that cleanliness is maintained. It is estimated that about 60% of the waste generated by a health care facility is general (nonhazardous) waste, about one-third of the 361 waste is recyclable (including compost), and biomedical waste constitutes only about 7% of all waste. Responsibility for waste 296 management shall be clearly defined, with a commitment to sustainability by reducing the amount of 296,361,362 waste generated through waste segregation and diversion (reusing and recycling). This will reduce the amount of waste categorized as biomedical and subsequently going for incineration or land disposal. In addition, they should be appropriate for the nature of the waste being collected. To prevent spillage and to protect the safety of waste handlers, waste containers should 296 not be overfilled. Legislation dictates that biomedical waste be handled and disposed of in a manner that avoids 2,3,92,219,229,363 transmission of potential infections:  Biomedical waste (excluding sharps waste) destined for incineration shall be placed in leak proof single use biomedical waste containers, which may be rigid plastic containers or cardboard 2 containers that are sealed and lined with a leak proof plastic bag that can be securely tied. Re 2 usable containers are not appropriate for biomedical waste destined for incineration. Reusable containers shall be puncture resistant, cleanable, and 2 disinfected after use. Single-use containers should have a lid that cannot be removed after the container is sealed; re-usable containers should have a lid that is locked 2 when the container is full. Biomedical waste should be segregated according to the categories listed in Table 4: Disposal Streams 2,3,296 for Biomedical and General Waste. Placing regular waste that does not require special handling into containers designated for biomedical waste will result in increased costs and may incur penalties from collection agencies. For waste from patients of viral hemorrhagic fevers, see:  Ontario Agency for Health Protection and Promotion (Public Health Ontario). For waste diversion (including reuse and recycling), see:  Ontario Hospital Association’s Greening Health Care Sector Report: Waste Management. In Ontario, all health care settings are required to use safety-engineered needles, according to the Needle Safety Regulation, O. Laundry staff can sustain injuries when needles or other instruments are accidentally left in bedding, linen or other laundry. Facilities shall have policies and procedures for managing sharps injuries (see 5. Occupational Health and 31,218,219 Safety Issues Related to Environmental Services) Environmental service workers must be provided with education about the facility procedure to be followed in the event of a sharps injury, 296 including immediate follow-up if a sharps injury occurs. A procedure for safely disposing of a contaminated sharp that has not been correctly disposed of may be found in Appendix 26. Refrigerated space at or below 4°C shall be 2,296 provided for storage of anatomical waste and for biomedical waste if stored for more than four days. Health care facilities shall have a contingency plan for dealing with the storage of refrigerated waste in 296 the event of:  excess waste production  the on-site cold storage unit or treatment equipment becoming inoperative  other disruption of disposal services 7. If a dedicated elevator is not available, waste should not be transported at the same time as clients/patients/residents, food serving carts or clean/sterile instruments/supplies/linen. Waste must be 2 transported by a certified waste hauler who provides a certificate of approval. In general, where the primary biomedical waste container is a sharps container or a rigid container with a nonremovable lid, additional packaging or containment of the waste is not necessary for off-site transportation. Where the primary container is a plastic bag, the bag shall be placed into a rigid, leak-proof outer container for 374 transportation off-site. For details on the classification, packaging, documentation and training requirements for shipping infectious substances, see  Transport Canada’s Transportation of Dangerous Goods Bulletin: Shipping Infectious Substances. It is strongly recommended 3,296 296 that non-immunized waste handlers be offered immunization against hepatitis B and tetanus. Health care facilities shall provide, and waste handlers shall wear, personal protective equipment 3,217,296 appropriate for the risk of the tasks when handling waste. Environmental service workers who clean reusable waste containers, carts, final storage areas, or biomedical waste treatment equipment also shall wear personal protective equipment appropriate for the tasks. Depending on the task and type of waste, examples of protective equipment may include:  Gloves to protect from exposure. Should not be transported on the same elevator as clients/patients/residents or clean/sterile instruments/supplies/linen. In this chapter, the use of antimicrobial surfaces within the health care setting and the use of “no-touch” disinfection systems are discussed. Microorganisms have also been shown to persist on surfaces even after routine cleaning 14,16 and to re-accumulate rapidly following cleaning. Candidate antimicrobial surfaces and coatings supported by data from nonclinical settings include 379-385 386-388 389 390 copper, silver, stainless steel coated with titanium dioxide, glass coated with xerogel, and 391 392,393 surfaces sprayed with surfacine or organosilane. With the exception of copper, there is very limited evidence that any of these approaches persistently reduce microbial contamination in clinical settings and no evidence that they reduce the incidence of health care-associated infection. There is now evidence from multiple studies demonstrating that copper surfaces used in acute and long-term care settings reduce overall bacterial burden. Additionally, one study using copper oxide impregnated linens 385 demonstrated a 24% reduction in health care-associated infection in a chronic care ward, and another study demonstrated a 44% reduction in health care-associated infection in the acute care setting among patients admitted to a room containing six copper items as compare to patients admitted to a room 380 24 with noncopper items. There is, therefore, insufficient evidence to recommend for or against the use of copper surfaces or copper impregnated linens in the health care setting, and facilities should weigh the cost, functionality, the limitation of copper (See Table 6) against its known antimicrobial properties, and low quality evidence suggesting it may impact infection rates when considering the use of copper surfaces or linens. There is insufficient evidence to recommend for or against the installation of copper surfaces. No-touch disinfection systems are systems that use chemical disinfectants or physical agents to disinfect surfaces and which do not require that the active agent is directly applied to and removed from the surface manually. The most studied no-touch disinfection systems include the use of hydrogen peroxide mist or 76,85,398-415 77,254,406,416-421 vapour or the use of ultraviolet light to disinfect surfaces. In all cases, these technologies were designed as a supplement to, and not as a 16,397,435 replacement for, routine cleaning and disinfection by environmental service workers. These technologies, the evidence for their use, are considered individually below. Hydrogen peroxide systems are effective against a wide range of 376,397 microorganisms, including bacteria, viruses and spores, particularly those of C. The vapour or mist is typically delivered by a computer-controlled distribution system that ensures even distribution throughout the room while monitoring gas concentration, temperature and relative humidity.

In neonatal intensive care units women's health clinic elko nv , systems for respiratory and metabolic support menopause the musical detroit , invasive or surgical procedures women's health diy boot camp , indwelling vascular lines women's health big book of exercises uk , and frequent use of broad-spec trum antimicrobial agents enable selection and proliferation of strains of gram-negative bacilli that are resistant to multiple antimicrobial agents. Multiple mechanisms of resistance in gram-negative bacilli can be present simul taneously. Carbapenem-resistant strains have emerged among Enterobacteriaceae, especially Klebsiella pneumoniae. The incubation period is variable; time of onset of infection ranges from birth to several weeks after birth or longer in very low birth weight, preterm infants with pro longed hospitalizations. Special screen ing and confrmatory laboratory procedures are required to detect some multiply drug resistant gram-negative organisms. Many experts would treat nonmeningeal infections caused by Enterobacter species, Serratia species, or Pseudomonas species and some other less commonly occurring gram-negative bacilli with a beta-lactam antimicrobial agent and an aminoglycoside. Expert advice from an infectious disease specialist can be helpful for management of meningitis. Several cases of infection caused by the same genus and species of bacteria 1 Centers for Disease Control and Prevention. Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. Periodic review of in vitro antimicrobial susceptibility patterns of clinically important bacterial isolates from newborn infants, especially infants in the neonatal intensive care unit, can provide useful epidemiologic and therapeutic infor mation. Clinical features of disease caused by each pathotype are summarized as follows (also see Table 3. Illness occurs almost exclusively in children younger than 2 years of age and predominantly in resource-limited countries, either sporadically or in epidemics. Asymptomatic infection can be accompanied by subclinical infammatory enteritis, which can cause growth disturbances. The illness is serious and typically develops 7 days (up to 3 weeks) after onset of diarrhea. Children presenting with an elevated white blood cell count (>20 × 10 per mL) or hematocrit less than 23% and with oligoanuria are 9 at higher risk of poor outcome. Each pathotype comprises characteristic serotypes, indicated by somatic (O) and fagellar (H) antigens. Human infection is acquired via contaminated food or water or via direct contact with an infected person, a fomite, or a carrier animal or its environment. Many food vehicles have caused E coli O157 outbreaks, including undercooked ground beef (a major source), raw leafy greens, and unpasteurized milk and juice. Outbreak investigations also have implicated petting zoos, drinking water, and ingestion of recreational water. The infec tious dose is low; thus, person-to-person transmission is common in households and has occurred in child care centers. The incubation period for most E coli strains is 10 hours to 6 days; for E coli O157:H7, the incubation period usually is 3 to 4 days (range, 1–8). Several sensitive, specifc, and rapid enzyme immunoassays for detection of Shiga toxins in stool or broth culture of stool specimens are available commercially. Most 1 E coli O157:H7 isolates can be identifed presumptively when grown on sorbitol-containing selective media, because they cannot ferment sorbitol within 24 hours. Antimotility agents should not 2 be administered to children with infammatory or bloody diarrhea. Careful monitoring of patients with hemorrhagic colitis (including complete blood cell count with smear, blood 1 Centers for Disease Control and Prevention. Recommendations for diagnosis of Shiga toxin-producing Escherichia coli infections by clinical laboratories. However, a controlled trial has not been performed, and a benefcial effect of antimicrobial treatment has not been proven. For an episode of severe watery diarrhea in a traveler to a resource-limited country, therapy can be helpful. Azithromycin or a fuoro quinolone have been the most reliable agents for therapy, although fuoroquinolones are not approved in people younger than 18 years of age for this indication (see Fluoroquinolones, p 800). Whenever possible, an antimicrobial agent should be chosen on the basis of results of susceptibility testing. All ground beef should be cooked thor oughly until no pink meat remains and the juices are clear or to an internal temperature of 160°F. Raw milk should not be ingested, and only pasteurized apple juice and cider products should be consumed. Strict attention to hand hygiene is important but can be insuffcient to prevent transmis sion. The child care center should be closed to new admissions during an outbreak, and care should be exercised to prevent transfer of exposed children to other centers. Exposed patients should be observed closely, their stools should be cul tured for the causative organism, and they should be separated from unexposed infants (also see Children in Out-of-Home Child Care, p 133). Travelers’ diarrhea usually is acquired by ingestion of contami nated food or water and is a signifcant problem for people traveling in resource-limited countries. Travelers should be advised to drink only bottled or canned beverages and boiled or bottled water; travelers should avoid ice, raw produce including salads, and fruit that they have not peeled themselves. Antimicrobial therapy generally is recommended for trav elers in resource-limited areas when diarrhea is moderate to severe or is associated with fever or bloody stools. Several antimicrobial agents, such as azithromycin, doxycycline, rifaximin, and ciprofoxacin, can be effective in treatment of travelers’ diarrhea. The drug of frst choice for children is azithromycin and for adults is ciprofoxacin. Packets of oral rehydration salts can be added to boiled or bottled water and ingested to help maintain fuid balance. People with diarrhea caused by these potentially waterborne pathogens should not use recreational water venues (eg, swimming pools, water slides) for 2 weeks after symptoms resolve. Fungal Diseases In addition to the mycoses listed by individual agents (aspergillosis, blastomycosis, candi diasis, coccidioidomycosis, cryptococcosis, paracoccidioidomycosis, and sporotrichosis) in section 3, infants and children with immunosuppression or other underlying conditions can become infected by uncommonly encountered fungi. Children can acquire infection with these fungi through inhalation via the respiratory tract or direct inoculation after traumatic disruption of cutaneous barriers. A list of these fungi and the pertinent under lying host conditions, reservoirs or routes of entry, clinical manifestations, diagnostic labo ratory tests, and treatments can be found in Table 3. Taken as a group, few fungal susceptibility data are available on which to base treatment recommendations for these fungal infections, especially in children. Consultation with a pediatric infectious disease specialist experienced in the diagnosis and treatment of invasive fungal infections should be considered when caring for a child infected with one of these mycoses. Invasive disease attributable to Fusobacterium species has been reported following otitis media, tonsillitis, gingivitis, and oropharyngeal trauma. Ten percent of cases of invasive Fusobacterium infections are associ ated with Epstein-Barr virus infection. Invasive infection with Fusobacterium species can lead to life-threatening disease. Otogenic infection is the most frequent primary source in children younger than 5 years of age and can be complicated by meningitis and thrombosis of dural venous sinuses. Invasive infection following tonsillitis was described early in the 20th century and was referred to as postanginal sepsis or Lemierre disease. Lemierre-like syndromes also have been reported following infection with Arcanobacterium haemolyticum, Bacteroides species, anaerobic Streptococcus species, other anaerobic bacteria, and methicillin susceptible and resistant strains of Staphylococcus aureus. Fever and sore throat are followed by severe neck pain (anginal pain) that can be accompanied by unilateral neck swelling, trismus, and dysphagia. People with classic Lemierre disease have a sepsis syndrome with multiple organ dysfunction, disseminated intravascular coagulation, empyema, pyogenic arthritis, or osteomyelitis. Persistent headache or other neurologic signs indicate the pres ence of cerebral venous sinus thrombosis (eg, cavernous sinus thrombosis), meningitis, or brain abscess. These fndings often resolve over several months and can indicate response to the infam matory, prothrombotic process associated with infection rather than an underlying hyper coagulable state. Human infection usually results from F necrophorum subspecies funduliforme, but infections with other species including F nucleatum, Fusobacterium gonidiaformans, Fusobacterium navi forme, Fusobacterium mortiferum, and Fusobacterium varium have been reported. Infection with Fusobacterium species, alone or in combination with other oral anaerobic bacteria, may result in Lemierre disease. Fusobacterium infections are most common in ado lescents and young adults, but infections, including fatal cases of Lemierre disease, have been reported in infants and young children. Children with sickle cell disease may be at greater risk of infection, particularly osteomyelitis.


  • Inflammation of the heart muscle (myocarditis)
  • Damage to the pituitary gland or hypothalamus from surgery, injury, tumors, infections, or radiation
  • Excitability
  • Smoking
  • Pale skin (pallor)
  • Prolactin levels
  • Infection of the heart or heart valves
  • HPV infection spreads from one person to another through sexual contact involving the anus, mouth, or vagina. You can spread the warts even if you do not see them.
  • Endoscopy -- camera down the throat to see burns in the esophagus and the stomach

The major concern in infection control relates to menstrual tissue discharge adult household members and con tacts who can be the source of infection pregnancy hormone . Household members and contacts should be managed with tuberculosis precautions when visiting until they are demonstrated not to pregnancy implantation have contagious tuberculosis women's health center of tampa . Nonadherent household contacts should be excluded from hospital visitation until evaluation is complete and tuberculosis disease is excluded or treatment has ren dered source cases noncontagious. Children who come from countries where M bovis is prevalent in cattle or whose parents come from those countries are more likely to be infected. Most infections in humans are transmitted from cattle by unpasteur ized milk and its products, such as fresh cheese, although human-to-human transmission by the airborne route has been documented. In children, M bovis more commonly causes cervical lymphadenitis, intestinal tuberculosis disease, and meningitis. In adults, latent M bovis infection can progress to advanced pulmonary disease, with a risk of transmission to others. This approach can be unreliable, and species confrmation at a reference labora tory should be requested when M bovis is suspected. Molecular genotyping through the state health department may assist in identifying M bovis. Controlled clinical trials for treatment of M bovis disease have not been conducted, and treatment recommendations for M bovis disease in adults and children are based on results from treatment trials for M tuberculosis disease. Initial therapy should include 3 or 4 drugs besides pyrazinamide that would be used to treat disease from M tuberculosis infection. For isoniazid and rifampin-susceptible strains, a total treatment course of at least 9 to 12 months is recommended. Parents should be counseled about the many infectious diseases transmitted by unpas teurized milk and its products, and parents who might import traditional dairy products from countries where M bovis infection is prevalent in cattle should be advised against giving those products to their children. When people are exposed to an adult who has pulmonary disease caused by M bovis infection, they should be evaluated by the same methods as other contacts to contagious tuberculosis. A plan to control and prevent extensively drug-resistant tuberculosis has been published. Eliminating ingestion 2 of unpasteurized dairy products will prevent most M bovis infection. Because children with tuberculosis usually are not contagious unless they have an adult type multibacillary form of pulmonary or laryngeal disease, their contacts are not likely to be infected unless they also have been in contact with an adult source case. After the presumptive adult source of the child’s tuberculosis is identifed, other contacts of that adult should be evaluated. Plan to combat extensively drug-resistant tuberculosis: recom mendations of the Federal Tuberculosis Task Force. Guidelines for the investigation of contacts of persons with infectious tuberculosis. Children with tuberculosis disease can attend school or child care if they are receiving therapy (see Children in Out-of-Home Child Care, p 133). They can return to regular activities as soon as effective therapy has been instituted, adherence to therapy has been documented, and clinical symptoms have diminished. The protective effcacy against pulmonary tuberculosis differed signifcantly among the studies, precluding a specifc conclusion. Disseminated fatal infection occurs rarely (approximately 2 per 1 million people), primarily in people who are immunocompromised severely. Reporting of suspected and confrmed cases of tuberculosis disease is mandated by law in all states. Physicians should assist local health department personnel in the search for a source case and others infected by the source case. Members of the household, such as relatives, babysitters, au pairs, boarders, domestic workers, and frequent visitors or other adults, such as child care providers and teachers with whom the child has frequent contact, potentially are source cases. Less common syndromes include soft tissue infection, osteomyelitis, otitis media, central line catheter-associated bloodstream infections, and pulmonary infection, espe cially in adolescents with cystic fbrosis. Symptoms can include worsening fever, swollen lymph nodes, local pain, and laboratory abnormalities. Several new species that can be detected by nucleic acid amplifcation testing but cannot be grown by routine culture methods have been identifed in lymph nodes of children with cervical adenitis. Rapidly growing mycobacteria have been implicated in wound, soft tissue, bone, pulmonary, central venous catheter, and middle-ear infections. Other mycobacterial species that usually are not pathogenic have caused infections in immunocompromised hosts or have been associated with the presence of a foreign body. Tap water is the major reservoir for Mycobacterium kansasii, Mycobacterium lentefavum, Mycobacterium xenopi, Mycobacterium simiae, and health care associated infections attributable to the rapidly growing mycobacteria M abscessus and M fortuitum. For M marinum, water in a fsh tank or aquarium or an injury in a salt water environment are the major sources of infection. Pulmonary disease and rare cases of mediastinal adenitis and endobronchial disease do occur. Most infections remain localized at the portal of entry or in regional lymph nodes. Outbreaks of otitis media caused by M abscessus have been associated with polyethylene ear tubes and use of contaminated equipment or water. Buruli ulcer disease is a skin and bone infection caused by Mycobacterium ulcerans, an emerg ing disease causing signifcant morbidity and disability in tropical areas such as Africa, Asia, South America, Australia, and the western Pacifc. Consultation with the laboratory should occur to ensure that culture specimens are handled correctly. For example, isolation of Mycobacterium haemophilum requires that the culture be maintained at 25ºC. Because these organisms commonly are found in the envi ronment, contamination of cultures or transient colonization can occur. Caution must be exercised in interpretation of cultures obtained from nonsterile sites, such as gastric wash ing specimens, endoscopy material, a single expectorated sputum sample, or urine speci mens and if the species cultured usually is nonpathogenic (eg, Mycobacterium terrae complex or Mycobacterium gordonae). An acid-fast bacilli smear-positive sample or repeated isolation of a single species on culture media is more likely to indicate disease than are culture contamination or transient colonization. Recovery of 1 American Thoracic Society and Infectious Disease Society of America. The interferon-gamma release assays use 2 or 3 antigens to detect infection with M tuberculosis. Although these antigens are not found on M avium-intracellulare, cross reactions can occur with infection caused by M kansasii, M mari num, and Mycobacterium szulgai (See Tuberculosis, p 736). Antimicrobial therapy has been shown in a randomized, controlled trial to provide no additional beneft. Therapy with clarithromycin or azithromycin combined with ethambutol or rifampin or rifabutin may be benefcial for children in whom surgical excision is incomplete or for children with recurrent disease (see Table 3. Isolates of rapidly growing mycobacteria (M fortuitum, M abscessus, and M chelonae) should be tested in vitro against drugs to which they commonly are susceptible and that have been used with some therapeutic success (eg, amikacin, imipenem, sulfamethoxazole or trimethoprim-sulfamethoxazole, cefoxitin, ciprofoxacin, clarithromycin, linezolid, and doxycycline). Clarithromycin and at least one other agent is the treatment of choice for 1 cutaneous (disseminated) infections attributable to M chelonae or M abscessus. Indwelling foreign bodies should be removed, and surgical débridement for serious localized disease is optimal. The decision to embark on therapy should take into consideration susceptibility testing results and involve consultation with an expert in cystic fbrosis care. M abscessus is diffcult to treat, and the role of therapy in clini cal beneft is unknown. Susceptibility testing to these agents has not been standardized and, thus, is not recommended routinely. Susceptibility testing to drugs other than the macrolides is not predictive of in vivo response and should not be used to guide therapy. Available data are not adequate to make recommendations for clarithromycin dose adjustments in these circumstances. Considerations are as follows: ♦♦ Most patients who respond ultimately show substantial clinical improvement in the frst 4 to 6 weeks of therapy. Elimination of the organisms from blood cultures can take longer, often up to 12 weeks.