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.