Articles on tuberculosis management

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 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

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.

Stress Management: How to Reduce Stress

Ms. Swati Kapoor, Dietitian/Nutritionist
Our lifestyle is getting busier day by day, as we are adding multiple works in our daily schedule and when we face difficulty in managing different areas we have put our hands in, we get stressed. You get stressed when you feel you have to handle more than you are used to. When you get stressed sudden changes occurs in your body like headache, upset stomach, trouble sleeping etc. It can make you moody, tense, or depressed and you are not able to concentrate on your work. It also weakens your immune system making it harder to combat the situation. If you are suffering from heart problems then stress is worst for you.  It’s very important to manage stress and reduce stress form our life, it will not only help you to make you feel better but by avoiding stress you will be able to avoid the problems which are caused by stress.Here we tell you some tips on how to reduce stress from our lives.Eat Healthy: Eating well and Healthy will provide you energy and all important nutrition that your body needs.  Eating well will help you to reduce stress (mental and Physical Stress). Taking a healthy diet will not only help you to reduce stress but will also help you boost your health. A healthy diet which includes plenty of omega-3 essential fatty acids, vitamins and minerals, can lift your mood.Relax: Try to keep relax; Relaxation might help you to reduce stress, Depression and Anxiety situations. Breathe calmly and slowly whenever you feel stressed out. Breathing will help you regulate your heart rate and help you to calm down.Sleep: - If you are not getting the right sleep you may feel stressed out. So, to reduce stress you need a regular and sound sleep.Exercise: Exercise is a great way to reduce stress. It helps your body produce endorphins; the neurotransmitters in your brain that make you feel good. It also forces you to focus, helping you forget what's making you anxious. Exercising in warm, sunny weather can boost your mood.Laugh out loud: There are so many things you can do to reduce stress. Enjoy a comedy movie, invite over some friends, and share a few good laughs. Every time you crack up, increased oxygen courses to your organs, blood flow increases, and stress evaporates. In fact, just thinking about having a good laugh is enough to lower your stress hormone levels.Go Out: It’s very important to keep your mind free from all the stress and depression. So, it’s better that you go out for a walk in a nearby park or garden or terrace. Fresh Air and environment also helps in reducing stress levels .Speak up: Not being able to talk about your needs and concerns creates stress and can make negative feelings worse. Assertive communication can help you express how you feel in a thoughtful, tactful way.Enjoy your hobby: Doing what you like may help you to reduce stress .When you engage yourself in something enjoyable, it can soothe and calm your restless mind. Try reading, gardening, crafts, tinkering with electronics, fishing, carpentry, music — things that you don't get competitive or more stressed out about.Stress management gives you a range of tools to reset your alarm system. Without stress management, all too often your body is always on high alert. Over time, high levels of stress lead to serious health problems. Don't wait until stress has a negative impact on your health, relationships or quality of life. Start practicing a range of stress management techniques today.

A Seven-Day Skin Care Regimen You Need to Start Today

Dr. Sharad Kulkarni, Ayurveda
Skin care is undoubtedly a must all around the year. A lot of skin care products are available, but how do you decide which is the best for you? The ingredients on the cover too can be confusing at times. Adding natural and herbal products to the skin and body care regimen is the best thing to do in such cases. Here is a seven-day skin care regimen that is sure to help you get healthy and glowing skin!MondayStart the week with a warm washcloth dab on the face, there by opening up the pores. You may apply a primer to decrease the presence of any pores. Later on in the day, try the ‘cheek bone squeeze’, which means that you pinch your cheeks for a couple of minutes to spread the blood flow and get a natural glow. Take half a papaya and mash it; apply it evenly on freshly washed skin. Leave it on for 10 to 12 minutes so that the enzymes in the papaya hydrate and infuse your skin with vitamin A.TuesdayCleanse your face first thing in the morning by using a simple or oscillating brush in circular motions. This will increase blood flow to your facial skin. After work or before going to bed, relax in your bathtub by adding some Epsom salts. This, too, will enhance your blood circulation that makes skin glow.WednesdayCleanse your face with a mixture of half milk and half water in the morning. The lactic acid in the milk revitalises the skin. Later in the day,mix a teaspoon of honey and three teaspoons of olive oil. This makes a great moisturiser. Apply it on your hands and face for a few minutes before bathing. Try an easy exfoliate at night for brighter skin. Mix two tablespoon of salt and half a teaspoon of lemon juice. Apply this mixture to your face incircular motions. Thereafter, rinse with warm water after 5 to 7 minutes.ThursdayCombat any cellulite you may have by spraying cold water on your legs for a couple of minutes after showering. Then, just like the ‘cheek bone squeeze’, try the ‘jawline pinch’. This time it is by pulling the jawline towards the hairline. This will provide elasticity to your skin and increase blood flow. Before bed, try a homemade face mask by mixing half a grated cucumber and one tablespoon of yogurt. Apply it on your skin and leave it on for about 15 minutes before rinsing off.FridayDuring the shower, use a loofah to wash away the dead skin uncovering the new healthy skin underneath. During your lunch break or afternoon naptime,place two slices of cucumber over your eyes. Leave on for at least 15 minutes. The beta-carotene in the cucumber acts as an antioxidant and reduces inflammation. Before bedtime, take half a lemon and sprinkle some sugar on it. Use this natural scrub on your skin to close down open pores and tone the skin.SaturdayIn the morning, mix two tablespoons of honey, one tablespoon of olive oil, one tablespoon of lemon juice and half a tablespoon of sugar. Apply this mixture on your face, leave it on for 10 minutes and rinse with water. This herbal face pack will remove dead skin and will brighten your complexion. Later in the day, place two tea bags in the fridge to cool down. After a couple of minutes, place them on your eyes for about 5 minutes. The caffeine in the tea shrinks the blood vessels around the eyes, there by decreasing puffy bags under your eyes. Before going to bed, remove all your make-up by using Vaseline. Then, mix half a cup of warm honey with three tablespoons of orange juice and apply it on your face for a healthy glow. Leave it on for about 20 to 30 minutes and then rinse off.SundayEnd your weekly skin care routine by putting your eye cream in the fridge. Once cool, apply it under your eyes and leave it on for about 10 minutes. To brighten the skin, mix a teaspoon of baking soda to your cleanser and apply. Leave for 5 minutes and use a cotton pad to remove and wash off.

5 Ways to Start Losing Weight Today

Ms. Harpreet Pasricha, Dietitian/Nutritionist
Most of us in the life try to lose weight with our own methods. Are you also one of them who wants to lose weight but aren't sure how to start? Worry no more. Follow my five easy steps to weight loss today. No more delays. No more waiting until Monday or the New Year. Follow these simple and effective steps and you'll get started losing weight today and keep it off tomorrow. 1. Carry a notebook and a pen.Make sure you write in that notebook! Every single thing that you swallow should be written in your notebook, preferably as soon as you swallow it. If you finish your daughter's leftover porridge at breakfast, write it down. Sample a cake at a friends place? Write it down. Just a 'taste' of the curry you're making for dinner? Write it down! Writing down what we eat and drink forces us to be aware of what we're putting in our mouth. It also gives us an easy way to track our intake and decide what changes we want to make.2. Ask 'why?'Every time you start to eat or drink, ask yourself one word: Why? Why am I eating this? Am I hungry, tired, bored, stressed, lonely? The correct answer is simple: hunger. If you're not hungry, don't eat. Figure out what you need to do to satisfy that emotion: Take a nap, read a book, yell at your spouse, call a friend -- just don't eat if you're not hungry.3. Eat to lose.That's right; if you skip meals you won't lose weight. Why not? Because then you'll get so hungry that you snack, or eat more than you want to, or end up feeling miserable and quit right away. Everybody needs to eat and deserves to eat three meals per day. Snacks, too (if, of course, you eat right kind). Wrong ways of dieting just leave you feeling hungry and unsatisfied. A meal should include whole grains, fruit and vegetables, protein and even a small amount of fat. 4. Remember your favourite things.If you've ever tried to completely avoid your favourite food, then completely lost control and devoured the entire bag of cookies, you know what I'm talking about. Stuck on chocolate? Eat one delicious, exquisite piece of high-quality chocolate every evening. Savour that chocolate. Sit down, relax, and do nothing but enjoy the flavour, texture and experience of eating the chocolate. Eat slowly, enjoying every bite. And whatever you do, don't feel guilty. A small portion of your favourite food will keep you satisfied and happy -- and losing weight.5. Find a part of your body that moves (not your mouth) and move it.Everyone can move something. If you have bad knees you can still exercise your arms or even do water exercises in a pool. Take up line dancing or karate. Walk the dog in the morning before work, take the kids for a bike ride after school, or listen to favourite music while using your treadmill. Even housework can become exercise if you move vigorously enough. There simply are no excuses for not moving.There you have it: five simple, easy-to-start steps toward weight loss and long-term weight management. Start right now.

Pain Management: Why Is It Important

Dr. G P Dureja, Spine and Pain Specialist
Most of the people suffer from different kinds of pain because of various reasons. Most of the people also tend to ignore it and move on. It is not advisable to ignore pain because you don’t know if that is casual or something serious to pay attention to. Avoiding pain will only make it worse, so it is essential to manage and treat pain. What is pain management? As the name suggests, managing your pain in a way that either it is treated or relieved, is pain management. It is also a branch in medicine called Pain Medicine, which involves in-depth procedures and techniques to ease out the pain. What are the types of pain?Majorly pain can be classified into two types, acute and chronic. Any pain that is short lived or short lasting comes under acute pain while, any pain that is long lasting or forever, comes under chronic pain. Chronic pain generally is the pain that lasts for 3 or more months. Based on, where, in the body, the pain is present, there are further three types. Somatic This type of pain is more like an exterior pain. Caused generally by the activation of receptors on the body surface or musculoskeletal tissues, it can be treated with proper rest and medication. Surgical pain comes under this type. Visceral Internal pain caused due to damage to the organs or tissues is known as visceral pain. This is not localized to just one body part. It might pain in different organs or body parts. Neuropathic Pain related to the spinal cord or peripheral nerves is called neuropathic pain. It generally occurs at the level or below the level of injury. How can you manage pain?Managing acute pain is easier than chronic. You can involve in a healthy lifestyle and physiotherapy but for advanced management and care, there are pain hospitals that manage pain well. These healthcare facilities are established especially to diagnose and manage chronic pain. What are the kinds of pain that can be treated?Various kinds of chronic pain can be treated in pain hospitals such as cancer pain, back pain, knee pain, neck pain, arthritis, fibromyalgia, migraine, etc. What are the treatments available? There are various treatment procedures that are involved in treating pain. These can be simple and complex both. It truly depends on upon the kind of pain you are suffering from. Some pain needs just lifestyle modification and counseling to be treated while the others require more complex treatments. Treatments like X-Ray guided injections, intrathecal pump implants, radiation therapy, Botox therapy and Platelet rich plasma therapy are some from a several more. These treatments can be very effective when performed by experts.

How to Manage Stress

Ms. Anu Priya, Alternative Medicine
MODERN LIFE IS FULL of deadlines, frustrations and demands, leading to the development of stress. But it isn’t always bad thing because a moderate amount helps you to stay focused as well as motivates your performance. However, if stress is too intense or is experienced for a long period of time, there can be harmful impacts to the mind and body, and may increase your chances of developing medical conditions such as high blood pressure, heart problems, depression, anxiety or other mental health conditions.Warning SignsStress can display emotional, behavioral, physicals and cognitive symptoms:The Tips to Manage StressPractice Relaxation TechniquesControlled breathing: Close your eyes and concentrate on your breathing. Take a slow deep breath in through your nose for three seconds, and then breathe out through your mouth for three seconds. Do this exercise for one minute.Progressive Muscle Relaxation: Close your eyes and focus on your body. Relax each muscle group from your feet all the way to your head. Tense the muscle as you breathe in, and then relax as you breathe out. Allow 15 to 20 seconds between each muscle group.Exercise RegularlyPhysical Exercise helps to relax tense muscle and reduce the level of stress hormones.Plan your time wellOrganize your time. Make a “to do list” and priorities daily tasks.Plan in advance and do not leave things to the last minuteReward yourself with little things that you enjoy (for eg. A massage or a movie) when you deserve it.Balance work and play; make time for doing things you enjoy.Maintain a healthy diet and sleep patternEat a well balanced diet; include plenty of fruits, vegetables and grains.Limit food intake that is high in fat, sugar and salt.Drink at least two liters (eight glasses) of water daily.Try to get six to eight hours of shut-eye every night. Sufficient sleep can allow you to focus better, be more productive, and deal with stressful conditions more efficiently.

Cupping for Overall Spine & Pain Management

Dr. Shaik.T, Alternative Medicine
Cupping Therapy  is indicated  for  blood disorders, pain  relief, inflammatory  conditions,  mental and physical relaxation,  varicose veins and  deep  tissue  massage and  quotes up  to  50% improvement in  fertility  levels.   Cupping is  an  ancient  method  of  treatment that has been  used  in the treatment  and cure  of  a  broad range of  conditions;  blood diseases  such  as haemophilia  and hypertension, rheumatic conditions ranging  from  arthritis,  sciatica, back  pain,  migraine, anxiety  and  general physical  and  mental  well-being. The  aim  of  Cupping  is to  extract blood  that  is believed  to  be  harmful  from  the body  which in turn rids  the  body  of  potential  harm  from  symptoms leading to  a reduction in  well-being  (Ullah,  2007). Wet-cupping  has been  used as an  alternative treatment  method  throughout  the  world,  especially  in Asia, the Middle  East  and  Europe. The  main  purpose of  this therapy  is to precipitate  the circulation of blood and  to  remove  blood-stasis  and  waste  from  the body(Kim, 2011). Benefits  of  Cupping: By  creating  suction and negative pressure, cupping  has been  found to affect the body  up  to  four  inches  into  the  tissues, which  is used  to treat muscle pain  and  spasms, drain  excess fluids and  toxins,  loosen  adhesions,  connective tissue and stubborn  knots in  soft  tissue,  stimulate  blood circulation  and  bring  blood  flow  to  nourish  stagnant muscles and  skin,  enhance  the  flow  of  energy, stimulate the peripheral  nervous  system, activate the lymphatic system, clear  colon blockages,  help activate and  clear  the arteries,  veins,  and capillaries, and improve  varicose veins. Cupping  draws the inflammation  out,  yet  does  not  add  to  it. Due  to its stimulating and strengthening effects cupping  has been used successfully  to  treat all of  the following: bowel  conditions (IBS, constipation  and  diarrhea), headaches, back  pain, arthritis,  period  pain,  injuries, asthma,  cellulite,  fatigue (ME), anemia, depression and emotional  problems, atrophy, sciatica, common cold and  flu, skin problems, blood  pressure, ladies problems, weight loss, and  more(Baird, 2011).