Implementation of DOTS-Plus requires the capacity to perform drug-susceptibility testing (not routinely available even in developed countries) and the availability of second-line agents, in addition to all the requirements for DOTS. DOTS-Plus is therefore much more resource-expensive than DOTS, and requires much greater commitment from countries wishing to implement it. Community engagement is a new approach that is being initiated alongside the DOTS individualized treatment. By creating a community for health workers to give support to patients and hospital faculty, the DOTS-plus model also incorporates psychological structural support treatments to help accommodate patients to ensure completion of treatment. Treatment with the new strategy is a total duration of 18–24 months.Monthly surveillance until cultures convert to negative is recommended for DOTS-Plus, but not for DOTS. If cultures are positive or symptoms do not resolve after three months of treatment, it is necessary to re-evaluate the patient for drug-resistant disease or nonadherence to drug regimen. If cultures do not convert to negative despite three months of therapy, some physicians may consider admitting the patient to hospital so as to closely monitor therapy. Extra-pulmonary tuberculosis
Tuberculosis not affecting the lungs is called extra-pulmonary tuberculosis. Disease of the central nervous system is specifically excluded from this classification. The United Kingdom and the World Health Organization (WHO) recommendation is 2HREZ/4HR; the US recommendation is 2HREZ/7HR.
Areas of the skull that are covered with muscle have no underlying diploë formation between the internal and external lamina, which results in thin bone more susceptible to fractures.Skull fractures occur more easily at the thin squamous temporal and parietal bones, the sphenoid sinus, the foramen magnum (the opening at the base of the skull that the spinal cord passes through), the petrous temporal ridge, and the inner portions of the sphenoid wings at the base of the skull. The middle cranial fossa, a depression at the base of the cranial cavity forms the thinnest part of the skull and is thus the weakest part. This area of the cranial floor is weakened further by the presence of multiple foramina; as a result this section is at higher risk for basilar skull fractures to occur. Other areas more susceptible to fractures are the cribriform plate, the roof of orbits in the anterior cranial fossa, and the areas between the mastoid and dural sinuses in the posterior cranial fossa. Prognosis
Children with a simple skull fracture without other concerns are at low risk of a bad outcome and rarely require aggressive treatment.The presence of a concussion or skull fracture in people after trauma without intracranial hemorrhage or focal neurologic deficits was indicated in long term cognitive impairments and emotional lability at nearly double the rate as those patients without either complication.Those with a skull fracture were shown to have "neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS".