Friday, 21 March 2014

Global Tuberculosis and aspergillosis - submission to UK All Party Parliamentary Group

Do some of the millions of smear negative ‘TB’ patients actually have TB at all? Drs Page and Denning have
submitted evidence submitted to the All Party Parliamentary Group on Global Tuberculosis (APPG-TB), UK addressing this uncertainty. Data from multiple sources suggests 15-20% of these patients may have chronic pulmonary aspergillosis (CPA).

Many smear negative patients fail to respond to empirical TB treatment often because of drug-resistance, or alternatively if the diagnosis was incorrect. CPA is a well described complication of pulmonary TB and can present with near identical symptoms and X-rays. Detection of CPA requires detection of Aspergillus antibody alongside chest X-ray or CT scan.

Currently CPA testing is not routine in patients who are TB smear test negative, but treating CPA can be effective with oral and IV antifungal drugs and more rarely with surgery. Such treatments are available globally are not routinely prescribed.

Importantly anti TB drugs lower oral antifungal drug levels to zero - rendering them useless - so it is vital to distinguish between the TB and its complication CPA.

The submission by Page and Denning working from the National Aspergillosis Centre in Manchester , UK, indicates that up to 20% of suspected TB cases will in fact have CPA. They suggest that patients screened for TB should also be screened for CPA using Aspergillus IgG initially - a simple blood test. One such blood test costs less than €1 per test. They highlight the critical importance of this test in patients with an apparent recurrence of symptoms after initial TB treatment. Their recommendation would be treat positive patients with the antifungal itraconazole, given its general availability - an early diagnosis would result in less lung damage.

The APPG-TB is co-chaired by MPs Andrew George and Virendra Sharma. Its objectives are:
·         To campaign for TB to be made a political priority for the UK Government, Political Parties and the international community;
·         To co-ordinate informed Parliamentary activity on TB;
·         To provide a forum for debate and discussion on issues relating to the global TB problem among Parliamentarians and other key stakeholders;
·         To promote effective and sustainable solutions that will have a positive impact on meeting global TB control targets;
·         To ensure that political and financial commitment for TB control from the UK Government and other sources is proportionate to the global need;
·         To work in partnership with other All-Party Groups on cross-cutting issues;
·         To build relationships with and support the activities of Parliamentarians in other countries who are working towards similar objectives;
·         To be recognised nationally and internationally as an influential and effective partner in the fight against TB.

Friday, 14 March 2014

Patients Know Best: A Personal Health Record

Mohammad Al-Ubaydli, founder and chief executive, Patients Know Best, recently had an article published in the British Medical Journal entitled 'Patients must have control of their medical records'. He writes the following:

Imagine an elderly patient with heart disease, arthritis, and a history of depression who needs social care at home. These are the patients who generate most of the work and cost in today’s developed world health systems, and usually their care is fragmented.
Our hypothetical patient sees two specialist nurses as well as different general practitioners at her local practice. She sees three sets of specialists, two of them at different hospitals, and she is to have a cataract removed at a third hospital. A carer comes every day, and she depends heavily on her three sons who share her care and live in different parts of the country.
Everybody accepts that this patient will have better care, and that costs to the health system will be lower, if her care can be integrated. But how can that be done? Well, one way—and perhaps the only way—is through the patient having electronic records that she controls herself: a personal health record.
This sounds like it has clear advantages to all concerned, not least the patients as they gain some control and some insight into what information every medical professional who attends them has access to - at the very least something that will reduce anxiety and confusion.
For example I was recently talking to a relative who had spent some time in hospital who on admission had to spend some time on pain relief and 'nil by mouth' in case of a possible urgent need for surgery. She noticed that several nurses and auxiliaries were not aware of whether or not she could be fed or given a drink and each had to go and find a particular nurse to find out - a waste of time and effort and vulnerable to error. If my relative had been able to write into a personal bedside record available to all it would have been far more efficient - the medical staff put up a notice but many missed it.

If you read the comments made about the article Doctors you will find that several doctors are concerned that they need a 'private' area to leave notes or access older notes written before the electronic era but I don't think it is being suggested that clinical notes will be replaced by a personal health record. Where the two systems cross over and what each has access to is an area for debate, as perhaps is the need for an expensive electronic personal record when a simple notebook and pen might suffice? Scratch that last comment - the book would probably go missing inside a few hours!

Monday, 10 March 2014

'Beijing cough' analysed

Beijing smog
Aspergillus and other microbes are commonly found in outdoor air throughout the world as their spores are extremely small and light, easily blown into the air by a slight disturbance. For the most part the lungs of a healthy person are well adapted to quickly removing these spores before any harm is done, but in some parts of the world the extent of air pollution is so extreme that there is some cause for concern - if not about fungal spores then about high levels of other chemical toxins and irritants.

In many parts of the world we have moved away from the widespread use of coal in the domestic setting to provide heat as some 60 years ago the importance of clean air was realised and enforced by government Act. Other parts of the world have not managed their air quite so effectively, perhaps for lack of available, affordable alternatives or geographical/atmospheric phenomena that mean the air around major cities occasionally become trapped and pollution accumulates.

In Beijing, China there are notorious levels of pollutants in the air on several days each year leading to a number of severe health problems and a characteristic 'Beijing cough'. Pollution is thought to be due to the extremely rapid growth of industry in China and the lack of pollution control.
Researchers have been using 'state of the art' air sampling and analysis techniques to find out what makes up a Beijing smog in terms of microbes that can be breathed in. Remarkably they have found evidence of around 1300 different species, some known to cause health problems not the least of which is Aspergillus fumigatus.

Scientists have found that the numbers of these potentially harmful species rise 2 - 4 fold on the worst smog days, and the next step is to test patients to see if the same organisms are causing increases in hospital admissions during the worst days of smog, or shortly afterwards.The pressure is on the Chinese government to take action!

Saturday, 8 March 2014

NHS Pays to Keep Patients Warm

The National Health Service (NHS) in the UK is the primary organisation that is responsible for caring for the sick. It is state-funded and extremely successful at prescribing effective drugs to the people that need them - care where it is needed, when it is needed. It is also taking on a more proactive role in prevention of illness as this tends to be more cost effective that fixing the damage once it is done!

One regional CCG  (specialist services provided by NHS funding) has interpreted its role in prevention a little further than most and instead of waiting for patients to turn up at hospital for (expensive) visits with asthma, infection, allergy and many other health problems caused by cold & damp, has opted to pay for the homes of vulnerable patients to be insulated and heated more efficiently.

Insulation and more efficient heating is certainly a good idea to help prevent hypothermia in the elderly and will help ward off damp and therefore the growth of moulds and bacterial that contribute to infections, but in time there is an extra somewhat counter-intuitive step to take. Warmth will hold more moisture in the air and as a result stop it being deposited onto walls & cold surfaces quite as quickly, but it hasn't gone away and in the absence of adequate ventilation it won't go away.

Efforts to keep heat in also stop ventilation in many cases - holes through which draughts flowed were once hated and plugged up, but this process has now gone so far as to mean some homes have very little means to allow warm damp air to escape. The damp now sits in  the home and will appear as soon as the air cools a little (e.g. at night). Result: disaster! Moulds & damp.

Tenants are often advised to open windows but again this is not advice tenants are likely to follow with great enthusiasm in cold weather - which is just the time when damp from this cause is at its worst.

We would like to suggest CCG's also take on board that ventilation is as important as insulation, and there are ventilation units that will keep warmth in a home while providing fresh air and constantly removing moisture. Heat recovery with mechanical ventilation units are capable of being the answer, but they must be expertly fitted as they can make matters worse if incorrectly fitted. The UK Institute for Specialist Surveyors and Engineers can provide help.

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