TB: preventable with early detection, treatment

By Carol Aloysius

While the number of TB cases has declined in recent years in Sri Lanka, due to several interventions, the numbers of new patients being detected is still significant to warrant concern. In 2011 according to statistics from the National Program for TB Control Chest diseases, there were 10,329 active TB patients of whom 18.8 percent and 12 percent were from Colombo and Gampaha districts. Deputy director Health Ministry Dr P.G. Maheepala told a media briefing Monday, that nearly 13,000 TB patients were detected every year and that many waited till the last minute to have themselves checked, thus risking their lives. It was due to this that Sri Lanka introduced the DOTS (Directly Observed Therapy) which led to a reduction in the number of cases in the country.

Myths and superstitions surrounding the disease have often had a negative impact both on the patients and their families. Due largely to wrong beliefs regarding TB, patients and families are often stigmatised. The result is that many patients even after being diagnosed with TB are prevented from going for treatment for fear that their illnesses will be revealed to others. This has compounded the situation for both the patients and their families since close contact with an untreated patient can lead to rapid spread of the disease in a household.

Consultant Respiratory Physician, Teaching Hospital/Chest Clinic, Kandy and President Sri Lanka College of Pulmonologists Dr Anoma Siribaddana shared her views with the Sunday Observer, to help explode the myths surrounding the disease.

Excerpts…

Question: What causes TB? Is it a virus? Or a bacterium?

Answer: It is caused by a bacterium called Mycobacterium tuberculosis.

Q: Is it an inherited disease? Are people born with it?

A. No. It is a contagious disease.

Q: Who is affected - everybody, only certain people?

A: Anybody can get affected with TB. Since TB is an air borne infection anyone who breathes air is at risk! But everyone who is infected will not progress to have the disease. It mainly occurs when the lung defences are reduced. In the majority of cases, TB affects the lungs (Pulmonary TB). But it can also affect any part of the body (Extra pulmonary TB). Around 90 percent of the people who get infected with TB, do not get the active disease. Only 10 percent of them will develop the active disease during their life time.

Q: Who are the most vulnerable victims?

A: In Sri Lanka the most vulnerable are smokers. There is conclusive evidence that the majority of those getting TB are males aged between 40-60 years largely due to their smoking habits.

Q: Why?

A: Smoking damages the lungs and reduces the lungs defenses. This makes the sleeping (dormant) bacteria which are living in our lungs to wake up ( reactivate and multiply) and cause the disease.

Q: Who else is susceptible to the disease?

A: Those with uncontrolled diabetes and other chronic diseases who also have lowered immune responses. Those with HIV/ AIDS are also liable to get TB due to the their poor immune responses. Due to their poor immune response, a person infected with HIV/ AIDS has a 21 percent - 34 percent higher risk of getting TB than a healthy person. TB is also one of the major causes of deaths among HIV/AIDS patients. If untreated the majority of patients with HIV/TB infection will die within the first few months of the infection.

Patients taking steroid drugs unsupervised are also at risk as this too can reduce the body’s defenses.

Q: Is diet a contributory factor-also poor nutrition does it contribute to getting TB?

A: Yes. Poor nutrition status predisposes to Tuberculosis disease.

Q: How can the disease be prevented?

A: BCG vaccination which is given at birth prevents an infant getting TB outside the lung but not disease of the lung.

Adults are not protected by currently available vaccines. Children under five years could be given drugs to prevent the disease when there is a TB patient in the household.

Q: Where do you find the largest number of patients? In towns? Villages? And why?

A:. TB is most prevalent in the towns and crowded areas, due to overcrowding causing inadequate ventilation. People with low socio-economic status are at higher risk of getting infected with TB due to their poor housing conditions without adequate lighting and ventilation, lack of adequate space that leads to overcrowding lead to the rapid spread of the disease in their neighbourhoods.

Q: Is diet a contributory factor - also poor nutrition does it contribute to getting TB?

A:. Yes. Poor nutrition status predisposes to Tuberculosis disease.

Q: Any other factors that contribute to the disease?

A:. Those on long term steroid therapy or with some other chronic diseases such as diabetes as I mentioned are more prone to get TB.

Q: What are the most common symptoms?

A: In most, TB is a disease of the lungs, although in about 25 percent of patients the disease occurs elsewhere in the body. Cough and low grade fever are the most common symptoms of TB of lung. Loss of weight and generalised weakness also can be present. A cough for over two weeks is the commonest presenting symptom of pulmonary TB. This may or may not accompany with shortness of breath, chest pain , night sweats, loss of appetite, loss of weight and excessive tiredness. Symptoms of the extra pulmonary TB depend on the organ affected and can be presented as enlarged lymph nodes , backaches etc.

Q: How is it diagnosed (a) in babies and children (2) adults?

A: In adults TB in the lung is very easily detected by examination of the sputum smears under direct microscopy. Chest X-ray also would be helpful.

Since babies cannot produce sputum samples the clinical presentation and the chest X-ray are used to diagnose TB. A skin test called the mantoux test also may be useful in some instances.

Q: Treatment methods – Drugs, DOTS

A: Sri Lanka uses the best regimes of drugs for treatment.

Tablets with Fixed drug combinations are available in the government health institutions.

These drugs are very effective. DOTS - Directly Observed Therapy Short course is a successful way of ensuring cure of TB.

Q: Why is DOTS so important?

A:. Though a patient should take anti TB treatment for six months duration, most of the symptoms disappear when the treatment commences. This makes many patients stop continuing the treatment. DOT strategy is adopted to overcome this situation and to achieve maximum compliance to the treatment.

Q: What happens if the patients does not take the full treatment?

A: If a patient does not complete the full course of treatment or takes it irregularly, the tubercle bacilli will become resistant to anti TB drugs. This situation is known as Multi Drug Resistant TB (MDRTB). MDRTB is very difficult to treat and needs longer periods of treatment with more expensive drugs. Adhering to DOTS prevents occurrence of MDRTB. It also helps to motivate the patient to continue treatment and provides opportunity for detection of adverse effects as well.

Q: Give us an example.

A: It was reported that high drug resistant forms of TB (XDRTB) had been detected in India and there is a risk of spreading it to Sri Lanka. By adhering to DOTS we can prevent this.

Q: Are these treatment measures effective?

A: Almost always. The most important fact is to follow the doctor’s instructions and take the tablets regularly.

Q: For a complete cure in normal situations, for how long should a patient take treatment?

A: For complete cure in normal situations, a patient should take treatment continuously for six months. In case of a relapse treatment is extended up to eight months.

Q: What about myths surrounding the disease?

A: One myth is that TB is a hereditary disease, which runs in families. Another degrading myth is to believe that it is a stigmatising disease.

Q: Your message?

A: TB is a completely curable disease. If one does not adhere to treatment, it may prove to be deadly. When one is on treatment the infectivity rapidly reduces and he may return to work while on treatment.

The undiagnosed are those that spread the disease but not the diagnosed patients on treatment.

How adolescent's brains make the transition to mature thinking

A new study conducted by monitoring the brain waves of sleeping adolescents has found that remarkable changes occur in the brain as it prunes away neuronal connections and makes the major transition from childhood to adulthood.

“We've provided the first long-term, longitudinal description of developmental changes that take place in the brains of youngsters as they sleep,” said Irwin Feinberg, professor emeritus of psychiatry and behavioral sciences and director of the UC Davis Sleep Laboratory. “Our outcome confirms that the brain goes through a remarkable amount of reorganisation during

puberty that is necessary for complex thinking.”

The research also confirms that electroencephalogram, or EEG, is a powerful tool for tracking brain changes during different phases of life, and that it could potentially be used to help diagnose age-related mental illnesses. It is the final component in a three-part series of studies carried out over 10 years and involving more than 3,500 all-night EEG recordings. The data provide an overall picture of the brain's electrical behaviour during the first two decades of life.

Feinberg explained that scientists have generally assumed that a vast number of synopses are needed early in life to recover from injury and adapt to changing environments. These multiple connections, however, impair the efficient problem solving and logical thinking required later in life.

His study is the first to show how this shift can be detected by measuring the brain's electrical activity in the same children over the course of time.

Two earlier studies by Feinberg and his colleagues showed that EEG fluctuations during the deepest (delta or slow wave) phase of sleep, when the brain is most recuperative, consistently declined for 9- to 18-year-olds. The most rapid decline occurred between the ages of 12 and 16-1/2. This led the team to conclude that the streamlining of brain activity - or “neuronal pruning” - required for adult cognition occurs together with the timing of reproductive maturity.

Questions remained, though, about electrical activity patterns in the brains of younger children.

For the current study, Feinberg and his research team monitored 28 healthy, sleeping children between the ages of 6 and 10 for two nights every six months. The new findings show that synaptic density in the cerebral cortex reaches its peak at age 8 and then begins a slow decline. The recent findings also confirm that the period of greatest and most accelerated decline occurs between the ages of 12 and 16-1/2 years, at which point the drop markedly slows.

“Discovering that such extensive neuronal remodelling occurs within this 4-1/2 year time-frame during late adolescence and the early teen years confirms our view that the sleep EEG indexes a crucial aspect of the timing of brain development,” said Feinberg.

The latest study also confirms that EEG sleep analysis is a powerful approach for evaluating adolescent brain maturation, according to Feinberg.

Besides being a relatively simple, accessible technology for measuring the brain's electrical activity, it is more accurate than more cumbersome and expensive options.

“Structural MRI, for instance, has not been able to identify the adolescent accelerations and decelerations that are easily and reliably captured by sleep EEG,” said Feinberg. “We hope our data can aid the search for the unknown genetic and hormonal biomarkers that drive those fluctuations. Our data also provide a baseline for seeking errors in brain development that signify the onset of diseases such as schizophrenia, which typically first become apparent during adolescence. Once these underlying processes have been identified, it may become possible to influence adolescent brain changes in ways that promote normal development and correct emerging abnormalities.”

medicalxpress

The tiny Bluetooth weapon in the fight against cancer

Updates on vital health information like proteins, sugar and organic acids in the blood can be displayed on doctor's mobile phone

A tiny implant that conducts blood tests under the skin could greatly improve the tracking and treatment of cancer and other diseases, researchers claim.

The 14 millimetre-long device is packed with miniaturised electronics including five sensors and a WiFi transmitter. Power is delivered through the skin by a battery patch which also relays test data via Bluetooth.

Results can be displayed on a doctor's mobile phone or laptop. The sensors target proteins, sugar and organic acids in the blood that provide vital health information.

For patients with chronic illnesses, such as cancer or diabetes, the device could provide continuous monitoring and sound an alert before symptoms emerge.

Scientists believe the implant will be especially useful as a chemotherapy aid. Currently doctors rely on occasional blood tests to assess a cancer patient's tolerance of a particular treatment dosage. However, it is difficult to tailor the ideal dose for an individual patient.

The implant opens up the possibility of much more finely tuned and effective treatment, according to Professor Giovanni de Micheli, one of the chip's designers from the EPFL polytechnic in Lausanne, Switzerland. “It will allow direct and continuous monitoring based on a patient's individual tolerance, and not on age and weight charts, or weekly blood tests,” said Prof de Micheli.

“In a general sense, our system has enormous potential in cases where the evolution of a pathology needs to be monitored or the tolerance to a treatment tested.”A prototype has already been tested for five different substances and found to be as reliable as conventional analysis methods.

The results were presented today at DATE (Design Automation & Test in Europe), Europe's largest electronics meeting taking place in Grenoble, France.Prof de Micheli's team hopes the device will be on the market within four years.

- PA

New disorder could classify millions of people as mentally ill

Millions of people could be mislabelled as mentally ill when psychiatry's bible of diagnoses is updated in May, warns a senior doctor in the weekly BMJ. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) - used around the world to classify mental disorders - will include a new category of somatic symptom disorder.

But Allen Frances, Chair of the current (DSM-IV) task force warns that the DSM-5 definition of somatic symptom disorder “may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making.”

The new category will extend the scope of mental disorder classification by eliminating the requirement that somatic symptoms must be “medically unexplained,” he said. In DSM-5, the focus shifts to “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviours.”

His concern is supported by the results of the DSM-5 field trial study. Somatic symptom disorder captured 15 percent of patients with cancer or heart disease and 26 percent with irritable bowel syndrome or fibromyalgia and had a very high false-positive rate of 7 percent among healthy people in the general population.

He points out that, previous DSM criteria “have always included reminders to clinicians to rule out other explanations before concluding that any mental disorder is present. But his suggestions to the DSM-5 work group that similar reminders should be included this time were rejected.

- MNT