Happy New Year - 2015

Dr. CS Rayat wishes his Followers & Friends “A Very Happy & Prosperous New Year-2015”.

“May every ray of the Sun fill your life with Success and Ultimate Happiness in 2015”

CS Rayat

Management of Tuberculosis: Diagnostic Approach

Accurate and timely diagnosis of Tuberculosis (TB) is a prerequisite for the treatment and control of spread of infection to other family members of the patient and health professionals dealing with patients. In the recent past several advances in the diagnosis and management of Tuberculosis (TB) have come out. Tools and technology are of great help in understanding of pathogenesis, demonstration of Mycobacterium, drug sensitivity testing and evaluation of prophylaxis.

Tuberculosis is a major health problem requiring early management at diagnostic and treatment level to bring down the mortality rate. In the developing countries the current mortality rate is 1 death per 100,000 population. The global incidence rate of Tuberculosis (TB) reported in the year 2010 was 128/100,000/year. To sustain the control and elimination of Tuberculosis (TB) there is a need for efficient testing and treatment regimens.

Diagnosis of Tuberculosis (TB) has conventionally been relied upon sputum microscopy of Micobacterium tuberculosis (an Acid Fast Bacilli) by Ziehl-Neelsen Staining Technique. The technique is very specific but has a poor sensitivity (around 50%). More sensitive technique used for demonstrating Acid Fast Bacilli (AFB) is by culture on Lowenstein Jensen Medium. Isolation of mycobacteria by culture method is considered to be gold standard in-spite of being time consuming.

The scenario of multi drug resistant TB (MDR-TB) has given a challenge to biomedical scientists to develop new drugs and diagnostic methods. Advances in molecular techniques for the diagnosis of TB have revolutionized diagnostic approach to this public health problem. Various new diagnostic modalities are based on the DNA extraction from the mycobacterial isolates. The nucleotide sequences of DNA are amplified and multiplied millions of times by polymerase chain reaction (PCR) for comparative diagnosis through detection of amplified DNA.

The tests that detect Mycobacterium tuberculosis antigens in clinical specimens could provide rapid and direct evidence of infection. The major targeted antigen of Mycobacterium tuberculosis is Lipo-arabino-mannan (LAM). LAM is detected in the urine of patients suspected of having pulmonary TB (Tuberculosis of lungs) as well as extra-pulmonary TB (Tuberculosis of organs other than lungs).

Molecular Tests are very sensitive and specific for diagnosis of infection and monitoring of treatment as well as for evaluating drug resistance. Uniplex-PCR (single insertion sequence IS6110 of 38 kDa)) or Multiplex-PCR (for multiplex targeting like IS6110 and MPB 64) are of great help for detecting drug resistance. Multiplex-PCR is more sensitive than Uniplex-PCR. Multiplex-PCR is useful in early detection, species differentiation (Mycobacterium tuberculosis or Mycobacterium avium) and epidemiology.

Two Molecular Assays used for rapid diagnosis of a case of TB and drug-resistance testing are:  i) X-pert MTB/RIF, and ii) Line Probe Assay (LPA)

i)                    X-pert MTB/RIF: X-pert MTB/RIF detects Mycobacterium tuberculosis (MTB) and resistance to Rifampicin (RIF) using Real-Time PCR (RT-PCR) Assay by amplifying MTB-specific sequence of the rpoB gene (inherent of MTB genome) that is probed with molecular beacons for mutations within the RIF-resistance determining region. Diagnosis of TB can be determined within 2 hours from the sputum samples with minimal health hazard. X-pert MTB/RIF test has 99% sensitivity and 100% specificity.

ii)                  Line Probe Assay (LPA):  Rapid detection of anti-TB drug resistance by Mycobacterium tuberculosis is the need of the hour for effective treatment and management of patient care. Line Probe Assays have been developed for rapid detection of rifampicin resistance and/or MTB-DR (especially rifampicin in combination with isoniazid). The Line Probe Assay (LPA) employs the hybridization of labeled PCR products with oligonucleotide probe on a strip and reading by colorimeter. The genotype MTB-DRplus Assay also simultaneously detects specific mutations in the katG gene conforming high level isoniazid resistance as well as in the inhA gene conforming low level isoniazid resistance.

The Molecular Assays are labeled for use on isolates from solid and liquid culture as well as directly on sputum smear positive pulmonary specimens. Mycobacterium tuberculosis ‘strain typing’ is very important for the analysis of the spread of tuberculosis as well as for monitoring the evolution of antibiotic resistance. These assays are also used to assess the bacterial load for monitoring of anti-TB treatment (ATT).

Just click the following link to update your knowledge about Management of Tuberculosis through Therapeutic Approach: http://drugsense.blogspot.in/2014/06/management-of-tuberculosis-therapeutic.html

Tuberculosis of Lymph Glands: A common type of surgical tuberculosis.

The tuberculosis in general comes under the domain of physicians, but several of its local manifestations are regarded as surgical tuberculosis. However, with powerful and effective anti-tuberculosis therapy majority of these cases can be treated without surgery. The tuberculosis of lymph glands is very common type of surgical tuberculosis. The lymph glands (filtering units of lymphatic system) commonly involved are those in the region of the neck; on one or both sides, above the clavicle. The affected lymph glands appear like a small or big lump with nodules. Initially the swollen lymph glands are painless, but later on the swelling may become soft due to breaking down of gland into a cheesy material and termed as 'cold abscess'.

Unlike an abscess or a boil due to acute infection, the glandular abscess is not 'warm' to touch. The abscess may break down, develop into a sinus and start discharging pus. The discharging sinus refuses to heal for a long time unless the patient is treated properly. It is worth remembering that every form of tuberculosis, in any part of the body leads to signs and symptoms of 'tubercular toxemia'. The 'tubercular toxemia' causes evening rise of temperature, weight loss, loss of appetite (anorexia), general weakness and sweating of body at night. The consultation of physician is must for early diagnosis and treatment of tuberculosis of lymph glands if above mentioned symptoms are there.

General Health & Mental Health: Role of Social Psychiatry

General health physicians should take into account the social milieu of the population. The social psychiatry plays a major role in the evaluation and management of mental health in addition to general health of a person. For example, we propagate compulsory immunization for children but at the same time we also educate our people for observance of sanitary principles; similar association exists between the general health and mental health. The practice of medicine is incomplete without the knowledge of social psychiatry. The social psychiatry has a unique place in the medical speciality of psychiatry.

Every psychiatric patient should not be considered a lunatic or insane person. Only severely regressed psychiatric patients are confined to custodial mental hospitals and 95% of psychiatric patients can be treated by general physicians having knowledge of social psychiatry. Psychiatry plays a vital role in social development. It has been established that economic and technological developments are not merely linear processes but extensions of individual personality factors.

For overall progress, the population will have to be motivated for achievement and guided for shedding traditional inhibitions to proceed on the path of industrialization and technological growth. Technological developments do have serious repercussions on mental health and quality of life. It is the universal truth that "Freedoms of life and pursuit of happiness can degenerate into a freedom to plunder, waste and pollute". Gene cloning, stem cell research, genetic engineering and organ transplantation are challenging and threatening the personal identity of one and all. Organs of underprivileged people are removed for transplantation in the elite and wealthy. The organ trade has denigrated the super-speciality of organ transplantation.

Mankind has developed and perfected the weapons of self destruction and annihilation. The entire issue of conflict between nations can only be solved through social psychiatry. To establish the world peace, nuclear disarmament is must and psychiatrists have a major role to play to format the mindset of international leaders.


Without mental health the life is meaningless. For meaningful life, coexistence of general health and mental health is must. We should never forget that general health adds years to life, whereas the mental health provides us purpose and meaning of living.

Olfactotherapy: Fortification of Memory through Smelling Sense

The smelling sense is the most mysterious and exclusive among the five senses of our body. Our smelling sense is linked with emotions and memory. If you look through the pages of history you would find many people addicted to smelling a particular essential oil or perfume. Napoleon was addicted to Eau de cologne. Olfactotherapy or aromatherapy is mainly used to recover the memory of patients who have suffered neurological trauma. Various essences (essential oils) and/or scents/fragrances are used in olfactotherapy. The olfactotherapy is said to be evolved and practiced in France in 19th century, however first Osmotheque (Repository of Scents) was founded in 1990 in France.

Olfactory system of our body is directly linked to central nervous system. The central nervous system develops very early in our fetal life. The neuronal groove is the very first groove that appears on the embryo. The stimuli of smell are brought to olfactory lobes of our brain by the olfactory cilia (miniscule hairs in our nasal cavity). The stimuli of smell are interpreted as sensations of fragrance by experience and recorded in the memory. An average person can recognize at the most 100 fragrances/aromas/scents/odors whereas a trained "Nose" (perfume maker) is capable of recognizing several thousand fragrances/aromas/scents/odors.

 The scents or fragrances used in olfactotherapy or aromatherapy are developed from more than 300 natural and synthetic essences/fragrances. New and old formulae of perfumes are archived at Osmotheque in France. There are very experienced Osmocurators at Osmotheque for creating and preserving perfumes. All perfumes/scents are preserved at 20^oC under argon gas to avoid evaporation.

The olfactotherapy acts through limbic system of our brain which controls emotions and memory. It has proved to be effective in reviving the lost memory in patients with neurological trauma. It is also effective in retarding the ageing process of our body and modifying mood & attitude. The fully functional smelling sense is a sign of good health.

Good Health: Role of Fresh Fruits & Vegetables

Proper nourishment is must for good health and vitality. Human happiness is linked to physical & mental health and employment. Productivity targets can only be achieved if we have good health. Balanced food or diet is must for building strong and fortified bodies. The best preventive medicine is nutrition. Only the individuals with strong immunity would have long lifespan. Consumption of fresh fruits and vegetables is must to acquire vigor and vitality. Fruits are unique in their flavors and taste. Fruits are known to attract eyes and enhance production of digestive juices.

Biological definition of fruits is different from the general notion. Fruits are produced from flowers or flower and are tissues of ripened ovaries or ovary along with adjacent tissue too. Fruits are eaten fresh or dry whereas majority of the vegetables are cooked. Fleshy, pulpy or juicy parts of fruits are eaten raw or used in food preparations. Let us look at the nutritive value of fruits:

Carbohydrates are energy constituents of fruits. The important fruit carbohydrates (sugars) are sucrose, fructose, dextrose and glucose. The water content in fruits is around 85%. A small amount of protein and traces of fat are also present in some fruits. Fruits are rich is indigestible fibre, minerals and vitamins. The caloric value of fruits is very high as compared to vegetables.

Fruits are rich source of vitamin-C. We know that vitamin-C boosts our immunity and saves us from scurvy. Vitamin-C is very strong anti-oxidant and protects us from ionizing radiation. It is known to heal bleeding gums. The citrus fruits are most dependable source of vitamin-C and are available around the year. Indian gooseberry (Phyllanthus emblica, Amla) is the richest known source of vitamin-C. The fruit pulp of Indian gooseberry (Phyllanthus emblica, Amla) has been reported to have 0.6% vitamin-C (i.e. 600 mg per 100 grams of fruit pulp).

The B-vitamins are in very low concentration in fruits. However fruits like grapes, pineapple, banana and custard apple have fairly good amount of B-vitamins. Deep orange and yellow colored fruits are an excellent source of b-carotene (precursor of vitamin-A). Vitamin-A is an essential nutrient for our optic nerves. So, consumption of fruits containing b-carotene (precursor of vitamin-A) would protect us from nutritional blindness. Papayas and mangoes are the best source of b-carotene (precursor of vitamin-A). Oranges, musk-melons, cape gooseberries, carrots and tomatoes are also a good source of b-carotene.

Calcium and minerals act as building materials of our skeleton as well as soft tissues. These are also regulators of metabolic functions. Iron is an essential component of hemoglobin. Iron, calcium and phosphorus are found in fairly good quantity in fruits. Apples, guavas, watermelons, raspberries, apricots, black grapes, dates and figs may contribute appreciable amount of iron to our diet. Fruits are also a rich source of cellulose and hemicelluloses which are also called complex carbohydrates (polysaccharides). Cellulose and hemicelluloses contribute to the indigestible bulk in the diet. Due to their fibre content fruits act as natural laxatives.

Aromatic compounds like methylbutyrate, higher esters or phenol derivatives give characteristic flavour and odour to fruits. Tannins present in some fruits have bitter taste and astringent action. Fruits containing tannins like gooseberries (Phyllanthus emblica, Amla) and Terminalia chebula (Harad or Haritaki) are good for our digestive system. Tannins are most commonly found in large number of raw (immature) fruits and some vegetables too. One must eat around 200gm fruits daily for good health and vitality.

Preventable Disabilities & Abnormalities

More than 100 million human beings suffer from physical and mental disabilities globally. These are generally caused by malnutrition and also known as nutritional disabilities. If we take the matter seriously; these are preventable disabilities. Malnutrition is a major cause of growth retardation, blindness due to vitamin-A deficiency and rickets due to vitamin-D deficiency. High fluorine content in drinking water may lead to fluorosis.

Over exposure to fluoride in drinking water or otherwise would erode the enamel of teeth; a condition called dental fluorosis. Children below the age of 10 years should not be allowed to use fluoride containing tooth pastes. Dental fluorosis is characterized by coloring and pitting of teeth. Over ingestion of fluoride in drinking water may lead to severe skeletal abnormalities also. Quality of drinking water should be assured by Public Health & Sanitation Departments of the area worldwide.

Deficiency of iodine in drinking water or food would lead to metabolic disorders and mental retardation in children as well as adults. In our body, iodine is processed by thyroid gland (an endocrine gland) present in the front of our neck. The colloidal substance present in the thyroid gland is a store house of iodine. The cells of the thyroid gland secrete an internal secretion called thyroglobulin; that breaks down to thyroxine hormone before being released into blood stream. Thyroxine is a tetra-iodo-compound (also called T4 hormone) that controls general metabolism of our body. Another thyroid hormone isolated from thyroid gland as well as present in blood/plasma is triiodothyroxine (also called T3 hormone). Under secretion of thyroid hormones in children produces cretinism. A cretin child grows up mentally retarded dwarf unless treated by thyroid extract. Goitre (enlargement of thyroid) and cretinism can be prevented with iodized salt or water.

Contamination of orange-red pulses (certain legumes of genus Lathyrus or kesari dal) may cause lathyrism (neuromuscular weakness). Seeds of Lathyrus cicera and Lathyrus clymentum are known to contain a toxin, causing neurolathyrism. Osteolathyrism is caused by a different toxin called beta-aminopropionitrile (present in sweet peas); that affects linking of collagen fibrils with bones and muscles. By careful sorting of legume seeds used as pulses Lathyrism can be prevented.


Protein calorie malnutrition (PCM) is another preventable abnormality/disability. Protein calorie malnutrition (PCM) leads to poor physical and mental endowment. Long term feature of PCM is mental retardation. Through the community education and awareness about nutritional value of food stuffs these nutritional disabilities can be prevented. Rickets is most common amongst malnourished children. Rickets is caused by deficiency of vitamin-D. Deficiency of vitamin-D leads to softening of bones and skeletal abnormalities in children. Children should be exposed to the sunlight as it leads to formation of vitamin-D from the pro-vitamin-D in our body. Butter, egg yoke and some species of fish are rich source of vitamin-D. So, intake of these and exposure to sunlight would be helpful for preventing rickets in our children.

Obesity: Cause, Consequences and Implications

There are many causes and health implications of obesity. Many people are in illusion about the quantitative parameters of obesity. The obesity can be defined in terms of Weight/Height (^W/_H) ratio or index: where weight is in kilograms (kg) and height is in meters (m). This index should be 25 to 30 normally. If your weight is 47 kg and your height is 1.60 m (160 cm); your ^W/_H index will be 29.375. An ideal weight of an individual with reference to sex, age, height and body build has already been documented somewhere else. The cause of obesity may be genetic, metabolic, physiological, lifestyle or pathological (as in cases of hypothyroidism). Take your weight on the same scale daily for a week. If you are overweight or your ^W/_H index is considerably more than 30, then plan to loose your weight through dieting and exercise. Never starve yourself. You can eat as desired from the unrestricted food items' list but remain within limits on restricted food items' list and keep away from prohibited food items' list:

Unrestricted Food Items' List
Unrestricted food items for the obese are fresh fruits, fresh vegetables, chicken, fish, poached eggs, boiled eggs (do not eat yellows), tea, coffee, skimmed milk and products made from skimmed milk.

Restricted Food Items' List
Restricted food items for the obese are all cereals and products made from cereals. Obese person should avoid eating more than 100 gm cereal products in a day. Fat consumption should not be more than 15 gm in 24 hours.

Prohibited Food Items' List
Prohibited food items for the obese are jams, honey, ice cream, dry fruits, nuts, cold drinks, alcohol, sugar and products containing sugar.


Obesity is associated with hyperlipidemia (elevated level of cholesterol and triglyrerides in blood), hypertension (high blood pressure), non-insulin dependent diabetes mellitus (NIDDM) and high prevalence of some cancers. Other serious implications of obesity are coronary heart disease and renal disease. Abdominal fat has been documented as major risk factor for coronary heart disease. The risk of NIDDM is more in overweight men aged between 25-50 years of age. The patient is said to have severe obesity if his ^W/_H index is more than 40. Natural history and consequences of obesity in children are not well understood till date. Strict dietary control and weight reduction would definitely help patients with severe obesity to overcome its serious implications like - NIDDM, hyperlipidemia, hypertension and coronary heart disease.

High-grade Fever with Pain in Tummy and Vomiting: May be Typhoid

Cases of typhoid fever are up during rainy season due to poor public health measures. Sanitation-wise filthy cities, uncovered and unwashed food stuffs are hazardous for travelers since typhoid infection is food borne. Typhoid fever is caused by bacteria known as Salmonella typhi or Salmonella paratyphi. There are two strains of Salmonella paratyphi, known as Salmonella paratyphi-A & Salmonella paratyphi-B. High-grade fever with pain in tummy associated with vomiting may be typhoid. Fever may rise upto 106^o F creating a scare in the family but never panic and call a physician or take the patient to the hospital. For an accurate diagnosis, germs of typhoid can be grown from the blood (Blood Culture Test) of the patient. However, there are some viral fevers which may mimic the symptoms of typhoid. If untreated, typhoid may lead to dire complications like perforation of intestine, hemorrhage (bleeding) and sudden bacterial shock. My contention is not to horrify people by citing the manifestations of this disease but spread awareness about prevention and timely treatment of it.

Science has enabled us to diagnose and treat typhoid effectively with antibiotics. Patient may be treated at home or at a hospital. But complete course of the recommended antibiotics should be taken to avoid relapse. Other members of Salmonella family (Salmonella paratyphi-A & Salmonella paratyphi-B) producing paratyphoid fevers and food-poisoning can also be treated well with antibiotics. Bacteria of Salmonella family are facultative bacteria and carriers of the disease continue passing the germs in their stool and urine.

Prevention is always better than cure and till we catch-up on community prevention; individual prophylaxis has to be very tight through vaccination. TAB vaccine is used worldwide to acquire protection against bacteria of Salmonella family. A variety of antibiotics are available to treat typhoid fever. Many countries have eradicated indigenous typhoid through meticulous and efficient public health measures. However, people traveling abroad are advised to get shots of TAB vaccine and cholera vaccine.

Tuberculosis: A killer of the poor !

The human race is indebted to Dr. Robert Koch of Germany for his landmark discovery of causative bacillus of tuberculosis in 1882. This discovery later won him (Dr. Robert Koch) the Nobel Prize. Dr. Koch worked on many other diseases also. He discovered the causative agent of Cholera in 1883 in Egypt. Both the discoveries of this renowned microbiologist are remarkable and revolutionary in the field of medical science. Dr. Robert Koch’s fundamental discovery of causative agent of tuberculosis set the pace of efforts worldwide to eradicate tuberculosis on the pattern of smallpox. Many nations in the world have already done so. Developing countries are still putting in efforts to eradicate the killer disease of the poor who cannot afford timely diagnosis and treatment in-spite of the free supply of anti-tuberculosis drugs.

Tuberculosis is still on the top of communicable diseases in many countries. Lack of awareness, poverty and associated malnutrition are the invitation for this communicable disease. BCG is the vaccination used to generate immunity against tubercle bacilli, but unfortunately the same has been failed to provide effective immunity in some geographical areas. The laboratory diagnosis of tuberculosis is largely based on x-ray study of the chest and examination of sputum for tubercle bacilli. Once diagnosed, the disease is curable.  Home-based treatment of tuberculosis is as effective and safe as the isolation ward of a hospital. At present the standard-regimen for treatment of tuberculosis is for six-months. However, a re-investigation and follow-up is must.  Extra-pulmonary tuberculosis can be diagnosed by cytological evaluation of 'fine needle aspirate' for tubercle bacilli. Polymerase chain reaction (PCR) is newer diagnostic method for Extra-pulmonary tuberculosis.

Participation of community is must for successful eradication of tuberculosis. If somebody is under treatment at a home, he/she should be confined to a room for at least two months of treatment, and all members of the family should bear mask in case of pulmonary tuberculosis. The preventive and curative efforts should move 'hand-in-hand' for successful eradication of tuberculosis.

Role of Simian Vacuolating Virus-40 (SV-40) in Causing Cancer/Tumors

The Simian vacuolating virus-40 (SV-40) is a polyoma virus. The SV-40 is a DNA virus that has the potential to cause tumors. Simian vacuolating virus-40 is believed to slash/suppress the transcriptional properties of tumor-suppressing p53 gene in human beings through its large T-antigen (SV-40 large T-antigen) as well as small T-antigen (SV-40 small T-antigen). It has been genetically established that SV-40 large T-antigen is the major protein involved in neoplastic process. The SV-40 large T-antigen predominantly exerts its effect through deregulation of tumor-suppressing p53 gene, which is responsible for initiating regulated cell death (apoptosis). The regulated cell death or apoptosis is a natural phenomenon that is must for maintaining shape and size of our body organs and tissues. The p53 gene is the most often mutated gene in human cancers. Due to its tumor suppressor role the p53 gene is invariably called the guardian of human genome. The p53 protein present in the cells, plays a major role in the regulation of normal cell cycle, differentiation of cells and cell death. The p53 gene also takes care of DNA repair, aging process and formation of blood vessels. It provides switching mechanism for activation and deactivation of transcription of its target genes by binding to the corresponding DNA sequences in the nuclei of cells. The cell cycle is arrested normally when a cell is damaged. Mutations caused by SV-40 virus in p53 gene would contribute to uncontrolled cellular proliferation, leading to a tumor. It has very well been reported in the medical literature that SV-40 is associated with brain tumors, malignant mesothelioma, non-Hodgkin lymphoma and bone cancers.


Immunohistochemical (IHC) testing is required to detect and demonstrate the viral infection in tumor tissue/biopsy. The immunohistochemical detection of simian vacuolating virus-40 (SV-40) could be culminated, using anti-simian vacuolating virus-40 (anti-SV-40) antibodies. The IHC testing on formalin fixed, paraffin embedded tissues has an advantage over immunofluorescence testing that one would have the convenience of archiving IHC stained slides for future reference. The worldwide availability of anti-simian vacuolating virus-40 (anti-SV-40) antibodies has given a boost to the research in this field.

Carcinomas & Role of Diagnostic Pathology

The word carcinoma is synonym for cancer or malignancy in medical science. Carcinomas may develop from a variety of epithelial tissues of various sites of human body. Epithelial tissues (layers of body cells lining the wall) of respiratory tract, gastrointestinal tract (GI tract) reproductive tract (vagina, cervix, uterus and fallopian tubes), oral cavity, head & neck, breast and skin may transform as carcinoma due to viral infections, genetic mutations and/or biochemical changes in our body. The histopathological diagnosis based on varied morphology of cells and their nuclei is very challenging for the pathologists. For the accurate differential diagnosis of carcinomas found in the primary organs and at metastatic sites in the biopsy materials/specimens, pathologists have to depend on advanced techniques/methodologies like immonohistochemistry (IHC), in-situ hybridization, molecular genetics, microarray etc.


A variety of panels of tumor specific & cells’ phenotype specific primary antibodies have been chalked-out through worldwide deliberations for accurate diagnosis of carcinomas/malignancies with reference to established literature and WHO classifications of carcinomas/malignancies. An accurate diagnosis provides the direction for the line of treatment or surgical interventions. However, individual results of advanced investigations may vary somewhat within diagnostic centers, probably due to protocols followed. The storage conditions and exhausted lifespan of primary antibodies used for IHC may influence the outcome of final result, so there is need for strict quality assurance at pathological diagnostic centers.