Articles on tuberculosis diagnosis

How Is Tuberculosis Diagnosed?

Dr. Madhukar Pai
Dr Madhukar Pai, MD, PhDDirector, McGill GlobalHealth Programs, McGill University, Montreal, CanadaAssociate Director,McGill International TB CentreIndia alone accounts for a quarter of all TB cases in the world. Over 2.2 million new TB cases occur every year and TB kills nearly 900 people every day in India. The emergence of severe forms of drug-resistant TB has worsened the situation, especially in cities like Mumbai.TB is a bacterial infection caused by Mycobacterium tuberculosis. While TB most affects the lungs, it can affect other parts of the body as well (e.g. lymph nodes, skin, bones, abdomen,urinary tract, nervous system).When should we worry about TB?All persons with otherwise unexplained productive cough lasting two weeks or more, or with unexplained chronic fever and/or weight loss should be tested for TB. Apart from chronic cough and fever, TB causes weight loss, loss of appetite, and tiredness. Night sweats can also occur.What tests are acceptable for TB diagnosis and what samples should be collected?Sputum is the ideal specimen to collect for pulmonary TB. All patients suspected of having pulmonary TB should have at least two sputum specimens submitted for microscopic examination and/or a World Health Organization (WHO) approved molecular test such as Xpert MTB/RIF (also called GeneXpert). Liquid culture is very useful in diagnosing smear-negative TB,and drug-resistant TB.Where are these TB tests available?In the public sector,sputum smears are widely available in designated microscopy centers and DOTS centers. GeneXpert is also available in the public sector, at the district level. Cultures are only available at reference hospitals and medical colleges.All TB tests are free in the public sector.In the private sector,tests such as GeneXpert, liquid cultures and line probe assays are available atmore affordable prices via the Initiative  for Promoting Affordable, Quality TBtests (www.ipaqt.org). More than 115 accredited labs are part of the IPAQTnetwork.What about chest X-rays?Chest radiography is useful but cannot provide a conclusive diagnosis on its own, and needs to be followed by sputum testing. Abnormal X-rays do suggest TB, but other lung conditions can also produce abnormalities on radiography. So, only relying on chest x-ray can result in over-diagnosis. Tuberculosis can only be confirmed by microbiological tests such as sputum smear microscopy, GeneXpert, and cultures.So, it is very important to order sputum tests that can directly detect Mycobacterium tuberculosis.What about blood test sand skin tests?There is no accurate blood test for active TB at this time.  There is no clinical role for blood-based antibody tests (e.g. IgG/IgM ELISA or rapid tests) and interferon-gamma release assays (e.g. TB Gold). They are not accurate and should not be used for pulmonary TB diagnosis.The Mantoux (tuberculin)skin test cannot distinguish latent TB infection from active TB disease, and has no utility for diagnosing pulmonary TB in adults. It has clinical utility in children, along with other tests such as chest x-ray, smears, and clinical history. Tests like Mantoux and TB Gold were designed to detect latent infection, and cannot separate latency from active disease.How is drug-resistant TB diagnosed?Drug-resistance testing can be done using two methods: genotypic and phenotypic. Genotypic methods are based on molecular tests that detect mutations in TB bacteria that confer drug-resistance. For example, mutations in the rpoB gene of Mycobacterium tuberculosis is strongly associated with rifampicin resistance. Examples of genotypic tests include Xpert MTB/RIF (GeneXpert), and Hain Genotype MTBDRplus (a commercial line probe assay). Phenotypic methods are based on detection of culture growth with and without TB drugs added to the culture media. Phenotypic methods include solid and liquid cultures. While solid cultures can take up to 2 months, liquid cultures (e.g. MGIT culture) can produce useful results within 2 weeks. All of these tests are available via the IPAQT network of private laboratories. They can also be accessed for free in the public/government TB program.

Tuberculosis: Correct Diagnosis and Treatment Can Save Lives

Dr. Madhukar Pai
Posted on World TB Day, by:Madhukar Pai, MD, PhDDirector, McGill Global Health Programs, Montreal, CanadaTB is an ancient disease that has plagued humans for centuries. Today, India alone accounts for a quarter of all TB cases in the world. Over 2.2 million new TB cases occur every year and TB kills nearly 900 people every day in India. The emergence of severe forms of drug resistant TB has worsened the situation, especially in cities like Mumbai.TB is caused by bacteria that are spread from person to person through the air. Long-term cough and fever are the most important symptoms of TB. When a person with TB coughs, TB bacteria get expelled into the air. The bacteria can then get inhaled by another person who can become newly infected. TB usually affects the lungs,but it can also affect other parts of the body. TB can affect adults and children, and can affect people from all walks of life. Persons with HIV infection and AIDS are particularly prone to getting TB.The positive news is that TB is treatable and curable. However, unlike most common infectious diseases (e.g. malaria or pneumonia) that require a few days of antibiotic treatment, TB requires several antibiotics and 6 months of treatment. Otherwise, TB bacteria will become resistant to antibiotics. Multidrug-resistant (MDR-TB) refers to TB that is resistant to rifampicin and isoniazid, two of the most critical first-line antibiotics used to treat TB.Accurate diagnosis: the first key stepBecause TB is a curable disease, it is very important to accurately diagnose the disease and to do it early, before severe lung damage occurs, and before other people in the community are infected.All individuals with cough for more than 2 weeks must seek care early and get their sputum tested for TB. Sadly, many persons with chronic cough do not seek medical care,and this results in long delays before a diagnosis is made. Sputum testing can involve microscopic examination for the TB bacteria, culture to grow the bacteria in a tube, or newer molecular tests that multiply and detect TB DNA. GeneXpertis the biggest new advance in TB detection. It is a highly accurate, molecular test that has been endorsed by the World Health Organization (WHO). This technology is completely automated and can rapidly detect TB as well as drug-resistant TB within 2 hours (photograph). Over 16 million GeneXpert tests have been done globally.Thanks to the Initiative for Promoting Affordable and Quality TB tests (www.ipaqt.org), led by the Clinton Foundation, it is now widely available in over 100 labs across India at prices that are 50% less than the market price. Through the IPAQT initiative other WHO-approved TB tests such as liquid culture are also available at subsidised rates.Correct and regular treatment can save livesIf TB is diagnosed, the most important thing a patient can do to is to take all of their medications exactly as prescribed by their doctor. No doses should be missed and treatment should not be stopped early, even if the patients feel better. Patients who cannot afford to buy drugs in the private sector must seek treatment in the public sector where drugs are available free of cost.Doctors have an important role to play in ensuring that their TB patients are treated correctly. Doctors must follow recommended treatment guidelines, monitor patients’ response to treatment, and make sure therapy is completed. Doctors should also avoid starting anti-TB drug treatment without doing any laboratory testing to confirm the disease. If TB is confirmed, they should start treatment promptly and follow Standards for TB Care in India.For regular, drug-sensitive TB, a standard 4-drug treatment must be started, and the total duration of treatment must not be less than 6 months. Drug-resistance usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs.If drug-resistance is suspected, it should be confirmed using laboratory tests such as GeneXpert and liquid culture. For drug-resistant TB, second-line drug treatment must be started, and the total duration of treatment must be at least 2 years. Treatment for MDR-TB can be very expensive in the private sector, and such patients can access free treatment in specialized public hospitals that can treat MDR-TB patients.With correct diagnosis and complete treatment, TB can be cured and loss of life averted.Importantly, this will also help control the spread of this deadly infection.

Tuberculosis Control Requires New Technologies and Approaches

Dr. Madhukar Pai
Professor Madhukar Pai, MD, PhDDirector, McGill Global HealthProgramsAssociate Director, McGill International TB CentreMontreal, CanadaAlthough much effort has gone into TB control, reduction in incidence has been disappointingly slow. India is a good example. Although India’s Revised National TB Control Programme (RNTCP) covers the entire country, and has met the 2015 targets, India continues to report over 2 million cases every year, and accounts for 1 of the 3 million ‘missing cases’ that are either not diagnosed, or not reported. One reason behind the observed lack of rapid reduction in TB incidence is the inability of programmes to rapidly diagnose and treat persons with TB, before the infection is transmitted to others. In India, a typical TB patient is diagnosed after a delay of about 2 months, and after having seen three different doctors. This underscores the importance of early diagnosis, of engaging private and informal sectors where patients often seek care, and suggests that more intensive efforts are necessary to identify the mission million patients each year.To control TB in India andelsewhere, we need new technologies (including novel tests and drugs), newpolicies, and new healthcare delivery models. We also need TB champions who canadvocate for more resources.New technologiesTB cannot be eliminated using tools that were developed decades ago. Most developing countries, including India, still rely on the sputum microscopy test. This method is more than a century old, and can only detect half of all TB cases. Furthermore, it cannot detect drug-resistance, which is a growing threat in India. Thankfully, new, accurate diagnostics for TB are finally here and are being implemented in India.The GeneXpert test is a rapid molecular test that can detect TB as well as drug-resistance within 2 hours. It is now being scaled up for TB diagnosis (pulmonary as well as extrapulmonary) and drug-resistance detection and over 16 million tests have been used globally. In India, this technology is being used in the RNTCP (which recently purchased 500 GeneXpert systems) as a rapid drug-susceptibility test, along with other WHO-endorsed tools like line probe assays and liquid cultures. In the private sector, these WHO-approved tests are now more affordable and accessible via the Initiative for Promoting Affordable and Quality TB Tests (IPAQT www.ipaqt.org).The IPAQT network has over 115 private, accredited laboratories across India,where WHO-approved TB tests such as GeneXpert and line probe assays are available at nearly 50% the market price. Currently used TB drugs were developed more than 40 years ago. The past couple of years has seen some breakthroughs in new drug development. Bedaquiline, a new drug to treat adults with MDR-TB, is the first new TB drug approved in over 40 years. Another new drug called Delamanid has also been introduced. In addition, efforts are underway to evaluate drug combinations (e.g. combinations containing PA-824, moxifloxacin and pyrazinamide) and these are expected to shorten duration of TB treatment from 6 to 4 months. Shortening TB treatment to even 4 months will increase cure rates, improve adherence, and reduce the risk of drug resistance. Currently, these new drugs are not freely available in India. It is important for India to streamline its regulatory and policy process, so that new drugs can reach the patients who desperately need them.New policies and standardsRecently, two majorstandards were published – the 3rd edition of the International Standards for TB Care (ISTC), and the first edition of the Standards for TB Care in India (STCI). These policy documents are based on the most current evidence, and already incorporate new tools like GeneXpert and newer WHO recommendations on treatment (e.g. acceptance of both daily and thrice-weekly intermittent regimens). These standards aim to inform physicians about the best approaches to TB detection, treatment and follow-up, and their acceptance and widespread use should reduce mismanagement of TB. In India, research studies show that most private practitioners do not follow international or national standards. This can result in poor quality of care, and increase risk of drug-resistance. Indeed, cities such as Mumbai are already dealing with a widespread problem of multidrug-resistant TB (MDR-TB), and even more severe forms of drug-resistance. Thus, it is important to educate the large number of private practitioners about STCI, and to check whether they are following the standards. A new TB book, aimed at private doctors, is now freely available at www.letstalktb.org New healthcare delivery modelsNew tools and new policies will need to reach patients who need them the most. This brings up the relevance of new business models and delivery innovations that can make quality care more affordable and accessible to patients at the base of the pyramid. TB patients need a complete and patient-centric solution, regardless of where they seek care(public or private). Engagement of the private sector for TB control is a key area where newer care delivery models are urgently needed. There are many good reasons topartner with the private sector for TB control. First, half of all patients with TB seek care in the private and informal sectors, and private practitioners (including informal and AYUSH practitioners) are often the first contact care providers. Many patients begin seeking care in the informal private sector, including chemists and unqualified practitioners. So, if we want to diagnose TB early and prevent further transmission, then engagement of such first-contact private providers is the critical. For example, India has over 8 lakh chemists, and many of them directly dispense medications for persons with classic tuberculosis symptoms. If chemists can be educated and engaged to refer such persons for TB testing, they could become a great source of active case finding.Second, there is plenty of evidence that quality of TB care in the private sector is suboptimal. Private doctors prefer blood rather than sputum tests for TB (e.g. TB Gold and TB Platinum) tha thave not been recommended by ISTC or STCI. Even if diagnosis is made correctly,TB treatment in the private sector is highly variable with a variety of irrational drug regimens, formulations and dosages. So, it is important for private practitioners to follow international and national guidelines and use the correct drugs and regimens.Third, even if the correct TB treatment is started, adherence is not guaranteed. All TB patients must complete the full course of treatment. Otherwise, outcomes can be poor. Thus,in the private sector, there is a need create systems to support patients during therapy. Mobile phones may be particularly helpful to send reminders to TB patients, and to make sure they come back for follow-up visits. Fourth, engagement of the private sector is necessary to increase rates of TB case notification. Since 2012, it is mandatory for all TB cases in the country to be notified to local health authorities (e.g. district TB officers). Unfortunately, most private practitioners and private hospitals still do not notify TB cases. Fifth and last, engagement of the private sector is critical to detect drug-resistance and ensure that all patients with drug-resistant disease have access to free second-line treatment that is available in the public sector. If patients cannot afford TB drugs, they should be referred to the public sector.In India, there are good examples of innovative and affordable models in healthcare – from artificial limbs (Jaipur foot), to affordable cataract (e.g. Aravind eye care system in Madurai) and heart surgeries (Narayana Health in Bangalore). There are novel models in the area of TB care as well, including Private Provider Interface Agency (PPIA) models in Mehsana, Mumbai and Patna, and Initiative for Promoting Affordable and Quality TB Tests (IPAQT). These models have used product and process innovations to serve the base of the pyramid.Currently, a Private Provider Interface Agency (PPIA) model is ongoing in Mumbai and Patna, to assess whether interface agencies can aggregate and incentivize private providers,educate them on STCI, improve quality of care and increase case notifications. Another project in Mehsana, Gujarat, is exploring the model of free drug vouchers for patients who are privately managed. These projects have provided free TB drugs to privately treated patients, helped increase notifications, and have also helped improve treatment completion rates. Another project is the Initiative for Promoting Affordable, Quality TB tests (IPAQT), a private lab network that has increased access to accurate diagnostics at lower costs. The government could evaluate these projects, and scale-up aspects that have worked well.Advocating for increased resourcesLastly, we need much more resources for TB control. Otherwise, new technologies and policies cannot be implemented at the scale required. In particular, the RNTCP desperately requires a substantially higher budget, if it has to deliver on the objectives laid out in the ambitious National Strategic Plan, which aims for “Universal Access.” Spending on health itself needs to be increased, given how little India invests in health. Without adequate financial resources, no program can tackle TB. Advocacy, is therefore, crucial –to raise public awareness, and to inspire political leadership. In the past year, TB advocacy has received a tremendous boost. In October of 2014, Satyamev Jayate, anchored by Mr Aamir Khan, featured an entire episode on TB. In December 2014, Mr. Amitabh Bachchan became an ambassador for TB control. A TB survivor himself, Mr Bachchan has featured in a wonderful ad campaign called TB Harega, Desh Jeetega (See YouTube videos at https://www.youtube.com/watch?v=9MiEQ1sqaDE). These are very positive signs, and will hopefully attract increased governmental and private investments in TB control.

Management of Tuberculosis: 10 Common Pitfalls to Avoid

Dr. Madhukar Pai
Indian TB patients get diagnosed after a delay of nearly two months, and are seen by 3 different providers before a diagnosis is made. At the primary care level, patients rarely get investigated for TB, even when they present with classic TB symptoms. Instead, providers give broad-spectrum antibiotics (e.g. fluoroquinolones) and remedies such as cough syrups and steroids. Even when TB is considered likely, private physicians tend to order tests that are non-specific, such as complete blood count, ESR, Mantoux test, and chest X-rays. They rarely seek microbiological confirmation via sputum smear microscopy, culture or polymerase chain reaction tests. Even if the diagnostic hurdle is overcome, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug regimens that are not recommended by WHO or the International Standards of TB Care. Furthermore, private practitioners often fail to ensure treatment completion, and provide adherence support to their patients. This article, one of the chapters of a new TB book called‘Let’s Talk TB’ aimed at GPs in India (published by GP Clinics, available free at www.letstalktb.org) discusses the 10 most common pitfalls that doctors should avoid. Addressing these pitfalls should great improve the quality of TB care in India.Pitfall 1: Not recognizing and suspecting TBDoctors inIndia often miss TB, because they do not suspect TB in patients presenting withcough for 2 weeks or longer.1 Multiple rounds of broad-spectrum antibiotics are tried, but tests forTB are rarely ordered at the primary care level.2 Even when TB is suspected, history taking is often incomplete – familyhistory of TB is rarely elicited, and previous treatment for TB is also missed.2Pitfall 2: Inadequate diagnostic work-upWhen doctorsin India think of TB, they often order non-specific tests such as total anddifferential blood counts (TC/DC), erythrocyte sedimentation rate (ESR), andchest X-ray.1, 2 While thesetests can be helpful, they do not confirm tuberculosis. Abnormal X-rays, forexample, do suggest TB, but other lung conditions can also produceabnormalities on radiography. So, only relying on chest x-ray can result inover-diagnosis. Tuberculosis can only be confirmed by microbiological testssuch as sputum smear microscopy, GeneXpert, and cultures. So, it is veryimportant to order sputum tests that can directly detect Mycobacterium tuberculosis.Pitfall 3: Use of inappropriate diagnostic testsActivetuberculosis is a microbiological diagnosis. Serological, antibody-based tests(e.g. TB ELISA) are inaccurate and banned by the Indian government.3 They should not be used for TB diagnosis. In India, there is growing concern that testssuch as Mantoux (tuberculin skin test) and IGRAs (e.g. TB Gold, TB Platinum)are being misused for active TB diagnosis. These tests were designed to detectlatent infection, and cannot separate latency from active disease. The Standards for TB Care in India (STCI) clearlystates that both TST and IGRAs should not be used for the diagnosis of activeTB in high endemic settings like India.3 If Mantoux and IGRAs are used for active TBdiagnosis, this will result in significant over-diagnosis of TB, because of thehigh background prevalence of latent TB infection in India. In children, STCIsuggests that the Mantoux test may have some value as a test for infection, inaddition to chest x-rays, symptoms, history of contact, and othermicrobiological investigations (e.g. gastric juice acid fast bacilli and XpertMTB/RIF).3Pitfall 4: Not considering the possibility of drug-resistant TB (DR-TB)DR-TB occurswhen patients fail to complete first-line drug therapy, have relapse, or newlyacquire it from another person with DR-TB. All persons who have previouslyreceived TB therapy must be considered to have suspected DR-TB. If patientshave any risk factors for drug-resistance, or live in a high MDR-TB prevalencearea (e.g. Mumbai city), or do not respond to standard drug therapy, they mustbe investigated for MDR-TB using drug-susceptibility tests (DST) likeGeneXpert, line probe assays, and liquid cultures. Indian physicians under-useDST and this can result in mismanagement.Pitfall 5: Empirical management ofsuspected TB with quinolones and steroidsWhen doctorssuspect TB or other lower respiratory tract infections, they frequently usebroad-spectrum fluoroquinolones (e.g. levofloxacin, moxifloxacin) for shortperiods. However, such empirical management with fluoroquinolones willmask and delay the diagnosis of TB. Fluoroquinolones, in particular, arebactericidal for M. tuberculosis complex. Empiric fluoroquinolone monotherapyfor respiratory tract infections has been associated with delays in initiationof appropriate anti-tuberculosis therapy and acquired resistance to thefluoroquinolones.4Doctors also tend to use steroids in individuals with history of chroniccough. Steroids, again, can result in temporary clinical improvement, but delaythe diagnosis and treatment of underlying tuberculosis.Pitfall 6: Once TB is diagnosed, not addressing co-morbidities andcontactsOnce TB isdiagnosed, it is important to make sure the patient is not suffering fromco-morbid conditions such as HIV and diabetes. It is also important to check ifthe patient is a smoker/alcoholic and provide them advice on smoking/alcoholcessation. It is also necessary to ask about TB symptoms among family members.In particular, small children living in the same family as the adult case mustbe tested for TB.Pitfall 7: Use of irrational TB drug regimensEven if the diagnostic hurdle is overcome, TBtreatment in the private sector is far from standard.1 Whenprivate practitioners initiate anti-TB treatment (ATT), they tend to use drugregimens that are not recommended by WHO or the Standards of TB Care in India(STCI). All patientswho have not been treated previously and do not have other risk factors fordrug resistance should receive a WHO-approved first-line treatment regimen fora total of 6 months.4 The initialphase should consist of two months of isoniazid, rifampicin, pyrazinamide andethambutol. The continuation phase should consist of isoniazid and rifampicingiven for 4 months. There is no need to add additional drugs suchas quinolones to the standard drug regimen.4 Also, thereis no need to extend the duration of treatment beyond 6 months, unless there isevidence of treatment failure, or there are complications (e.g. bone &joint TB, spinal TB with neurological involvement and neuro-tuberculosis). Drugdosages should be based on body weight, and daily dosing is preferable.4Some physicians have the mistaken perception that second-linemedication are more potent than first-line medication. In fact they are lesseffective (and more toxic) medications, and should be reserved only forpatients with drug-resistant TB, or first-line drug intolerance.Pitfall 8: Not ensuring treatment adherenceAdherence to the full course of ATT is critically important to ensurehigh cure rates and to prevent the emergence of drug-resistance. But privatepractitioners struggle to ensure adherence. Most do not maintain any medical records,and this makes it very difficult to follow-up patients. Patients often do notreceive sufficient counseling about the importance of completing the fullcourse of ATT. Drug-related side effects (if not adequately counselled on at theoutset) is another common reason for non-adherence, and possible treatmentdefault.Every TB patient should receive counseling atthe start of TB treatment. Bynotifying all TB cases to the local health authorities, private practitionerscan seek help from the public sector to help follow-up patients who default.Physicians can also work with community-based organizations, and enlistcommunity health workers to supervise treatment.Pitfall 9: Not monitoring response totherapy and changing regimens without DSTOnce ATT is started, doctors have theresponsibility of monitoring the patients to check whether therapy is working.This requires follow-up smear and culture testing. Negative smears at the endof therapy is important to ensure cure. If a patient is not responding to ATT,it important to investigate why. Addition ofa single drug to a failing regimen is a big concern. Many physicians add aquinolone to the 4 first-line drugs (HRZE) when the standard therapy does notresult in improvement. This is wrong, and can result in MDR-TB.Sometimes, patients end up moving from one doctorto another, and each time the drug regimen gets modified without adequate drug-susceptibilitytesting (DST) to guide the choice of drug combinations. This creates a perfectenvironment for drug-resistance to emerge or worsen.Pitfall 10: Not notifying all cases and using free publicsector services for vulnerable patientsTB treatment is available free ofcost to all patients in India via the Revised National TB Control Programme(RNTCP).5 So, privatepractitioners can refer all TB patients for treatment through the RNTCP, unlesspatients insist on being treated in the private sector. RNTCP provides a rangeof services such as contact investigation, linkage to free TB drug programs,adherence support, and linkage to PMDT services for patients with MDR-TB.5 By availingthese free services, patients can protect themselves from catastrophic healthexpenditures. Irrespective of where thepatients are diagnosed and treated, it is mandatory for private practitionersto notify all TB cases to their respective District or Corporation TB Officers.REFERENCES1.          SatyanarayanaS, Subbaraman R, Shete P, et al. Quality of tuberculosis care in India: asystematic review. Int J Tuberc Lung Dis2015; 19(7): 751-63.2.          Das J, Kwan A, Daniels B, et al. Useof standardised patients to assess quality of tuberculosis care: a pilot,cross-sectional study. Lancet Infect Dis2015 (published ahead of print).3.          World Health Organization CountryOffice for India. Standards for TB Care in India. URL: http://www.tbcindia.nic.in/pdfs/STCI%20Book_Final%20%20060514.pdf (dateaccessed 7 April 2015), 2014.4.          TB CARE I. International Standards forTuberculosis Care, 3rd Edition. URL: www.istcweb.org  (date accessed 7 April 2015)2014.  (accessed.5.          Sachdeva KS, Kumar A, Dewan P, KumarA, Satyanarayana S. New Vision for Revised National Tuberculosis ControlProgramme (RNTCP): Universal access - "Reaching the un-reached". Indian J Med Res 2012; 135(5): 690-4.This article was originallypublished in GP Clinics as part of a supplement entitled Let’s Talk TB. Other chapters of this book can be downloaded freelyat www.letstalktb.org

Premature Ejaculation: A Deeper Study of Statistics, Causes & Diagnosis

Dr. Yuvraj Arora Monga, General Physician
In my previous article posted, we learnt about premature ejaculation, what is this actual condition and how it is defined. Today we will learn about Statistics, Diagnosis & Type of Premature Ejaculation, Why and how it happens?Statistics of PE:Premature Ejaculation-PE is a common sexual complaint. You are not alone! Estimates vary, but as many as 30-40 % men across the world including India experience problem of PE at some time of life. Approximately 30%-70% of American males experience premature ejaculation. The National Health and Social Life Survey (NHSLS) indicate a prevalence of 30%, which is fairly spread across all adult age groups.Diagnosis of PE:As per DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ), the specific criteria for premature (early) ejaculation are as follows:In almost 75-100% sexual activity, the experience of ejaculation occurring during sexualintercourse within 1 minute after vaginal penetration and before the individual wishes it.The problem above has persisted for at least 6 months.  The symptoms above cause significant mental stress to the person. The dysfunction cannot be better explained by any other nonsexual mental disorder, any medicaldisease, the effects of a drug or medication, etcSeverity of P.E.The severity of premature (early) ejaculation is broadly defined as follows:Even the severe form is not uncommon. Many times men approach the doctors with complaint that they are not able to penetrate the vagina. They ejaculate on minor physical stimulation and it is occurring again and again. Not able to achieve pregnancy is another big concern. If the premature ejaculation is so severe that it happens before commencement of sexual intercourse, conception will not be possible unless artificial insemination is used. Types and Characteristics of P.E.Premature ejaculation can be Chronic (lifelong) or acquired (recent).With chronic (lifelong) premature ejaculation, the person has been experiencing premature ejaculation since he became sexually active (ie, post puberty). Usually it is seen that premature ejaculation starts occurring from the beginning of his sexual activity probably the first sexual intercourse or even the discharge occurs early on masturbation as well.With acquired (recent) premature ejaculation means that the condition began in an individual who previously experienced an acceptable level of ejaculatory control and had successful sexual relationships and only now has developed premature ejaculation in the recent past (few weeks to months). How to approach a person with Chronic (lifelong) or acquired (recent) Premature EjaculationIn patients with Chronic (lifelong) premature ejaculation, the treating doctor or sexual therapist should enquire about the following:ü  Atmospher at Work or schoolü Relationships with friends or brother /sistersü General attitude toward sex by himself and or familyü Previous psychological problemsü Early sexual experiencesü Any bad feelings about sex that relates to 1 or more bad experiences encountered duringgrowing years of lifeü Type of the relationship / sexual engagement (eg, married / non married / live inrelationship)ü Sexual attitude and response of the female partnerü Non sexual aspects of the current relationship ( comfort level & trust factors)Clues from above and similar questions usually point toward possible reasons/factors that may be addressed specifically with therapy by the treating physician or sexual therapist.In patients with acquired (recent) premature ejaculation, the treating doctor or sexual therapist should enquire about the following:         Erectile dysfunction  Performance anxiety ( it is seen very commonly in men i.e., they want to show a good performance in the sexual act with the female partner)ü Psychotropic drug use or alcohol consumptionü Previous & Current relationshipü Nonsexual aspect of the current relationship ( comfort level & trust factors)ü Level of involvement of the sexual partner during sexual actsü Sexual response of partnerü Stamina or fitness level for prolonged intercourseWHAT CAUSES P.E.?Not a single particular cause is responsible for causing premature ejaculation. It can either occur when you indulge in sexual activity with a new partner or if it’s been too long since the previous ejaculation.However, the causes of premature ejaculation can be divided into two broad sub-heads, which are psychological or biological cause:Psychological causes:Premature ejaculation is believed to be a psychological problem and does not represent any known organic / physical disease involving the male reproductive organs or any known defect in the brain or nervous system.Psychological causes behind premature ejaculation may include the development of a certain pattern that is hard to change and is a result of your previous sexual experiences.One of them most common reason is childhood habit of reaching climax / ejaculation quickly because of fear of discovery when masturbating as teenagers or during early sexual experiences with female partner.  This pattern of rapid attainment of sexual release is difficult to change in later stage of life during marriage or long-term relationships.Other reason is situations in which you may have hurried climax / ejaculation in order to hide your problem from your female partner; or feelings of guilt that make you rush through sexual encounters. Other psychological causes include anxiety and relationship issues which can also result from deep anxiety about sex that relates to bad experiences encountered by the patient during development (e.g. incest, sexual assault, conflict with parents, etc.)Biological causes of premature ejaculation:Many scientists have questioned whether premature ejaculation is purely psychological. A number of investigators have found differences in nervous stimulations and hormonal differences in men who experience premature ejaculation compared with individuals who do not. Some believe that some men have hyper-excitability or over-sensitivity of their genitalia, which is again not proven.Abnormal functioning of the ejaculatory systemThyroid problemsInfection or inflammation of the urethra or prostate Nerve damage occurring due to trauma or surgery (a very rare cause) Abnormal levels of hormones and/or neurotransmitters (which are chemicals present in the brain) have been many times said to be responsible for PE likeTestosterone is thought to play a role in the ejaculatory reflex. Higher free and total testosterone levels have been demonstrated in men with premature ejaculation than in men without premature ejaculation Recent article in a Chinese andrology journal showed that semen from men withpremature ejaculation contained significantly less acid phosphatase and alpha-glucosidase than did the semen of control subjects.Another study found that many men with premature ejaculation have low serum prolactin levelsSomehow these biochemical markers may contribute to premature ejaculation, organic and psychological associations (eg, anxiety) suggest that these biochemical markers play only a partial role. Further research is needed.In part 3 and 4, we will discuss how to approach the men / couple suffering from premature ejaculation to resolve this problem. The therapy includes wide spectrum of approach including counselling, behavioural methods, exercises, techniques and medical remedies both modern as well as alternative medicines.

What Is Cerebral Palsy? Symptoms, Diagnosis and Treatment

Dr. Vykunta Raju K. N, Neurologist
What is Cerebral Palsy (CP)?Cerebral Palsy is primarily a disorder affecting the movements and actions performed by various muscles of the body (motor disorder). Though described as non progressive the disability (due to the damage sustained at a time during early childhood) can progress.How common is CP?Most place the prevalence around 2 per1000 children. In India, no absolute figures are available, but estimated children affected (based on hospital records) are over 2.5 millions.How do you recognize C.P.?§ The hall mark of the condition is motor dysfunction, i.e. there is abnormal muscle tone, abnormal posture and movement§ As the child grows, the movement disorder can appear worse because every effort to move is confronted by the force of gravity§ The clinical expression of the child depends on the extent and area of brain damage, growth of the child, coexisting developmental problemsWhy is it important to know about CP?§ Ignorance about the problem often causes more problems for a person with C.P. than the condition itself.§ Actually a child with C.P. is not hopeless§ Half the children with C.P. have average or above average I.Q.§ With timely help and proper guidance a vast majority can lead active, self supporting and long livesEarly diagnosis of CPWarning symptoms§ Lack of alertness§ Increased abnormal movements, Fits§ Feeding problems, drooling§ Poor quality of sleepAbnormal signs§ Reduced head size or fall in its growth§ Delayed social smile§ Poor head control present at 3 months of age§ Delayed appearance of developmental milestones§ Constant fisting after 2 months of age§ Increased tone, scissoring or assumption of equinus position of feet§ Eye problems: roving eyes, no visual following, persistent squint§ Lack of response to soundConditions that mimic CP§ Birth defects-neural tube defects, vertebral instability etc.§ Slowly progressive degenerative brain disorders e.g. metabolic disorders - amino aciduri as like glutaric acidemia type I, peroxisomal disorders, mitochondrial disorders§ Neuromuscular disorders e.g. muscular dystrophies.In all cases where the diagnosis is in doubt, further follow-up and diagnostic evaluation may be required.Role of investigationsDiagnosis of CP is essentially clinicalü Laboratory tests are not necessary to confirm diagnosisü Brain imaging studies including Ultrasound scan of brain, CT and MRI may be useful in elucidating the cause of cerebral palsy and suggesting a long term outcome.ü Ultrasounds can head is easily available in most health centers and is useful to detect bleeding and periventricular leucomalacia in preterm babies.ü CT and MRI - to detect / diagnose other diseases that may be confused with CP e.g. slow degenerations, birth defects etc.Eye and hearing assessmentü  Always screen systematically for visual and auditory problems even if they may not be clinically apparentMANAGEMENTBenefits of early interventionü  Anatomical - Maintains soft tissue extensibility, optimises musculoskeletal growth and developmentü  Physiological - Early visual and sensory inputs optimize movement, posture and balanceü  Developmental - Reinforces positive developmental patternsü  Reduces cost of treatment, minimizes complications and mitigates need for adaptive equipmentWho does the CP management team consist of?Multidisciplinary approachThe CP management team consists of a Child neurologist, developmental pediatrician, physiotherapist, a child psychologist, orthopedic surgeon, speech therapist, occupational therapist and a social worker. The neurologist coordinates the functioning of the team and is primarily involved in diagnosis, assessing development and disability. Control of fits if any and determining the need for any interventions-medicines, surgery or otherwise.How is CP managed?The management of CP revolves around the management of associated conditions (like fits, mental subnormality, visual and hearing loss) prevent the progression of disability and rehabilitation.Counseling: A physician should have an elementary idea of all the modalities required for holistic management.Physiotherapy and motor trainingPhysiotherapy should be directed towards:ü  Specific training of actions such as sitting, standing, walking and steppingü  Exercises designed to increase muscle strengthü  Prevention of contracturesü  Control of movementTraining in activities of daily livingManagement of feeding difficultiesü  Usea shallow spoon, soft foods.ü  Place the food on the middle of tongueü  Give small pieces of solid foodü  If needs help to keep mouth closed when chewing, apply pressure to jaw to keep it closedü  Drooling can be minimized by improving swallowing, drugs not very effectiveEarly developmental stimulationBasic principles areü  Follow  general principles of normal developmentü  Attempt to break the primitive reflexes as they interfere with attainment of normal milestonesEducational problemsü  Children with mild CP do well in mainstream schoolsü  Most children with moderate to severe cerebral palsy need to be educated in special schools.Eye problemsü  Check for refractive error, advice eye exercisesCommunication problemsü  Encourage child to speak. Guidance from speech therapist can help improve speech patternsFITSü  Management is same as for other children with fitsü  However,a larger proportion of children with CP may have refractory fits or require drug therapy for prolonged periods. Avoid phenobarbitone.Counseling of the familyThe doctor should emphasize that CP is:ü  Not a mental illnessü  Not necessarily associated with mental retardationü  Not contagiousü  Not inherited (except in rare cases)ü  Not curable but treatment aims at minimizing disability to improve their quality of life.Aim of the schools is not to admit them and segregate them from their family and peer groups but to provide an insight and train the parents and school teachers about the special needs of these children and their strength and weakness.Social awarenessü  All CP children do not have low IQ and least 1/3rd have average 1Qü  They are not a burden on the society and can contribute activelyLegislature – passed on 22nd December,1995 – disability bill for equal opportunities.ü  Equal opportunities, protection ofrights and full participation. As per this act the government and local authorities shall ensure that every child with disability has access to free and adequate education till the age of 18, integrate students with disabilities into normal schools, set up special school, for those in need of special educationü  Employment – posts are identified for disabled personsü  Non-discriminationü  The government shall within economic limits, undertake rehabilitation programs for persons with disabilities

Attention Deficit Hyperactivity Disorder: Important For Your Complete Understanding

Ms. Manavi Khurana, Psychologist
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neuropsychiatric conditions of childhood and adolescence affecting 4-12% of children, with a significantly higher percentage of males being diagnosed. ADHD is a persistent problem, manifesting its core symptoms throughout the life cycle, with impairments reflected in a child’s academic performance, peer relationships, family functioning, self-esteem and overall quality of life.Despite its high societal cost, the syndrome is poorly understood. The intent of this article is to educate parents and teachers about the signs and symptoms of ADHD leading to early diagnosis and consequent early intervention.ADHD is a syndrome, reflecting a cluster of symptoms, which are grouped under three broad categories- inattention, hyperactivity and impulsivity. Both the DSM-5 and ICD-10 (manuals for diagnosing mental disorders) share these core clinical criteria. It is important to remember that the symptoms should be maladaptive and inconsistent with the development of the child.ADHD is a condition which is pervasive and persistent: it pervades into a wide variety of situations over a long period of time that disturbs functioning and lowers quality of life. The symptoms should have been present continuously for 6 months by the time the child reaches the age of 7 years.Inattention symptoms include: not paying close attention to details or making careless mistakes in work, failing to sustain attention in activities, not appearing to listen what is being told, failing to follow through instructions, impairment in organising tasks, avoiding or strongly disliking activities requiring sustained mental effort, losing things frequently, and being easily distracted by external stimuli.Hyperactivity is reflected by the following: Fidgeting often with hands or feet or squirming in the seat, often leaving seat in situations where remaining seated in expected, running about often or climbing in situations which are inappropriate, being unduly noisy, and seeming ‘on the go’.Impulsivity symptoms include: Blurting out answers before questions have been completed, failing to wait for one’s turn, interrupting or intruding on others, and talking excessively.More often than not, there is a mixed picture in children, reflecting some parts of all three criteria. Of these core criteria, hyperactivity (because of the distress it causes to the caregiver) is often the quickest to be observed and picked up, and often becomes the reason for psychological referral.Often when children are referred to mental health services, parents/ teachers describe them as being overly naughty and disobedient. The nature of the symptomatology is such that it is easy to misattribute the ADHD syndrome (especially the hyperactivity and impulsivity type) to plain naughtiness, leading to harsh punishment being meted out to the child for no fault of his own.On the other hand, at times true ADHD symptoms are overlooked, because it is a common belief that it is normal for children (especially males) to be naughty during their developing years. Though there is a higher prevalence of the condition among males as compared to females (4:1), recent research has suggested that the rates among girls might be highly underrepresented.This is because of the stereotype of someone with ADHD is a hyperactive little boy, and girls usually don’t fit into that. Their symptoms differ from those of the boys (more of the inattention type, hence less disruptive to the caregivers) which makes it less likely that they will be noticed.The causes of ADHD are manifold. Most of the research evidence points towards genetic factors and disturbances in brain functioning (which explains why the condition is a neuro-developmental one).Environmental factors are more important in maintaining the condition rather than causing it. Parents often blame themselves for their child’s condition and wonder what they could have done to prevent it. Knowing that the cause is biological (and hence out of their control) may help in absolving themselves of the blame. Needless to say, parents, teachers and caregivers go through an enormous amount of distress in handling a child with ADHD. Mostly they unsuccessfully resort to physical punishments and other aversive procedures such as extreme criticism, failing to realise the ineffectiveness of the strategies.With all the negative connotations attached to the diagnostic label of ADHD, one may easily overlook the immense difficulties that children with ADHD have to face each day. Enduring mockery, punishments and criticism from everyone around them brings intense feelings of shame, low self-esteem, sadness, and anger.Children sometimes deliberately display “bad behaviour” in order to mask the real issues they face. For an accurate and complete diagnosis, it is imperative that the child is assessed by a Psychologist.Assessments are usually paper-pencil tests completed across multiple settings- at home, at school and at the clinic. Direct observation, standardized tests and subjective reports are combined to arrive at a diagnosis. An early diagnosis leads to early intervention, which prevents the magnitude of difficulties that the child and caregivers would have to otherwise face. Intervention strategies are multi-modal in nature. The parent, the school and the (various) mental health professionals work in collaboration to manage the child’s condition. It is important to recognise that the child spends a lot of his/ her time in school and hence it also becomes the school’s responsibility to provide the appropriate environment for the child.Children with ADHD often endure a lot of bullying by their peers and are neglected by them. With schools and its teachers holding academic performance as the benchmark of evaluating children, the needs of a child with ADHD are somewhere lost. Parents and teachers need to work closely with the mental health professional in order to gain a better understanding of the child and make an individualistic behavioural management plan for the child keeping in mind his interests, hobbies and personality traits. Cognitive remediation exercises are also taught to the child in order to increase his attention span.Medication is given in a few cases (especially to children with extreme hyperactivity). There is understandably a considerable amount of parental anxiety regarding the side effects and addictive properties of such medications. Research points to the fact that the side effects seem to be low in comparison to the potential benefits of the medication. Monitoring a careful increase in dosage, appropriate timing and precise watch over any side effects should be done by the caregiver and the treating psychiatrist.Parents often wonder whether their children will ever get cured of the condition. It is important to know that because ADHD is a neuro-developmental problem, it may be excellently managed but not cured. This means that there needs to be a continuous effort by the parent, child and the school to work in unison with the treating team in order to deal effectively with the problem. The realisation that the issue is the condition and not the child himself will go a long way in managing target symptoms and helping the child lead his life smoothly.

How to Manage Your Erectile Dysfunction Effectively

Dr. Yuvraj Arora Monga, General Physician
There are enough options available which can keep every man sexually active regardless of the cause of erectile dysfunction (ED). However, it is important to get treated by a physician who is willing to give time to understand your problem and identify a suitable and most appropriate therapeutic option.Counselling Sessions:As with an electrical circuit, if there are any breaks in the system it will not function as a unit. Part of the process of psychosexual therapy would be to think about the actual emotional and/or psychological issues behind ED, and to attend to these with weekly counselling sessions. This realisation is an important first step for you to begin and resolve your erection problem. The patient normally implements the therapy advice at home, either alone or with a partner, between therapy sessions. This may help you maintain an erection for once, gradually building confidence.Relieving sexual anxiety:Telling your partner before you make love that you have this anxiety, and the feelings it causes. As a result, your partner will understand, and the two of you can work on it together.You can reduce some worries by being more giving with foreplay, even if your sexual performance isn't what you or your partner wanted, your partner will still be satisfied.Consider regular exercise which brings confidence in your body as your energy is also an important part of overcoming sexual anxiety.Non-Medical TherapiesWatermelon juice (Nature’s Viagra) & Ginseng (Herbal Viagra): L-Citrulline, an amino acid, present in watermelon can bring about significant improvement in blood flow to the penis, showing an improvement in erectile function. Another herb called Ginseng, specifically “red ginseng,” is known as the “herbal Viagra” that can improve sexual performance. Several research studies provide evidence for the effectiveness of these herbs in ED treatment.Kegel exercises: Pelvic exercises, involving the portion of the body between your waist and thighs, are commonly known as kegel exercises. Three months of kegel exercises twice daily can help to significantly improve your erection ability which strengthens the penile muscle. They also promote urinary control.Acupuncture therapy: The acupuncture needles are placed in the wall of the abdomen. By stimulating specific acupoints, the practitioner aims to restore the proper flow of energy in the body resolving ED.Eat  Right: Scientific study at Massachusetts on Male Aging has found that eating a diet rich in fruit, vegetables, fish, lesser red and processed meat, whole and refined grains decreased the likelihood of having ED. Intake of daily multivitamin and fortified foods is the best remedies for treating ED.Walking: Just 30 minutes of walking a day is linked with 41% drop in risk for ED. Moderate exercise can help restore sexual performance in obese middle-aged men with ED.Attention towards vascular health and making body slim: High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the penis along with heart and brain thereby leading to ED. Maintaining a trim waistline is a good defence for ED, as men with a 42-inch waist are 50% more likely to develop ED in comparison to 32-inch waist people.Avoid excessive alcohol: Chronic heavy drinking of alcohol can cause liver damage, nerve damage, and other conditions, interfering with the normal balance of male sex hormone (androgens) levels ultimately leading to ED.Intake of L-arginine: L-arginine, an amino acid, which is naturally present in the body and helps make nitric oxide, supports a successful erection. Nitric oxide is responsible for making the blood vessels relax, which helps sustain an erection for men.Medical therapy:ED can also be treated with oral medications, drugs insertions or injections into the penis. Oral medications that are normally prescribed to treat the dysfunction work for about 80% of men. They work by boosting the natural signals, which are generated during sexual activity so as to help you sustain an erection. Alprostadil is a type of medicine that causes blood vessels to expand, increasing  blood flow to the penis, thus facilitate an erection. Cialis, Levitra, Staxyn and Viagra work by a similar mechanism to cause erections. There are subtle differences in how long the drug works and how quickly it works.But kindly note drugs like Viagra are not recommended for normal person for recreational use. They should not be used as performance enhancing drugs for they also have their set of side effects and hence, should be taken under medical supervision.A vacuum erection device is a plastic tube that slips over the penis, making a seal with the skin of the body.  A pump at the other end of the tube creates a low-pressure vacuum around the erectile tissue, which results in an erection.Ayurvedic Medications:Klaibya in Ayurveda is defined as an inability to attain and keep sufficient rigid (firm) erection which is essential during sexual intercourse for the sexual needs or the needs of his female partner. Also, Vajikarana in Ayurveda means producing a horse's vigor. Some of the herbs used in Vajikarana include:Bulb of Allium sativum (Garlic) Root of Asparagus recemosus (Shatavari)Root of Boerhavia diffusa (Punarnava)Whole part of Cocculus cardifoli (Guduchi)Root of Panax ginseng (Ginseng)Seeds of Myristica fragraus (Nutmeg)Leaf & Root of Withania somnifera (Ashwagandha)Leaf & Seeds of Ginkgo bioloba (Ginkgo)Pitch of Asphaltum bitumen (Shilajit)Dried root of Lepidium Meyenii (Maca)Again please remember, all the above drugs/ remedies  should be taken under medical supervision after consultation from registered medical practitioner after proper diagnosis has been made.

Proper Diagnosis Is Must

Dr. Vishal Jain, Dentist
My this article will insist for the proper diagnosis and treatment planning before starting any dental treatment.Normally, dental pain is severe in nature and is radiated to ear, head and neck. It is very difficult for the patient to locate the source of the pain. Sometimes patient may not tell you the correct details. Wrong arch means pain is in the upper arch (maxilla), but patient keeps on insisting for pain in the lower (mandible). So, it should be the dentist's duty to listen calmly to the chief complain of the patient, take proper history like severity, duration, aggravating/ relieving factors, location etc. then, check clinically and try to relate history with the clinical findings. If still further tests are required, do not hesitate and go for IOPA, OPG or even scan before starting treatment. I insist here that before starting the treatment, dentist should educate patient by telling the procedure in detail, show treatment procedure by photos or videos, clear all his doubt, make him comfortable then only start the procedure. Patient will be confident and co-operative to you during the treatment. Simultaneously, it is patient's duty also to let the dentist do all the investigations and examination before treatment. These investigations are for the benefit of the patient and helps dentist to treat you more precisely. Be calm and co-operate in answering all his questions about your sickness. Please mention your previous dental history if any, either good or bad.Wishing all the readers a very healthy smile.