The different types of Analgesics

By

The Department of Pharmaceutical Services,
Ministry of Health


WHAT IS AN ANALGESIC?
An analgesic or painkiller is a group of drugs used to treat and relieve pain. The word 'analgesic' is derived from Greek, an- ("without") and algos- ("pain").

HOW DOES ANALGESIC WORK?

Analgesic drugs act in various ways on the peripheral and central nervous system. The pain relief induced by analgesics occurs either by blocking pain signals going to the brain or by interfering with the brain's interpretation of the signals, without producing anesthesia or loss of consciousness.

WHICH ANALGESIC IS BEST FOR ME?

An analgesic is chosen according to the location, severity and type of pain. The severity and response to other medication also determines the choice of agent. Types of pain such as in neuropathic pain, traditional analgesics are less effective and there is benefit from other drugs that are not normally considered analgesics eg tricyclic antidepressants and anticonvulsants.

Types of analgesics:

1) Paracetamol (Acetaminophen)

The exact mechanism action of paracetamol is unknown but it appears to be acting centrally in the brain to make a person less susceptible to pain. It also affects the hypothalamus which helps to regulate normal temperature. It is used to reduce fever and in mild to moderate pain such as headache, toothache, muscle and joint pain, backache and period pain. Paracetamol has very few side effects and it is relatively inexpensive. It is regarded as a safer analgesic when taken at the normal recommended doses but excessive doses more than 4g per day or on long-term use can lead to kidney and liver damage. There are various formulations (tablet, soluble tablet, suspension & suppository) and brands of paracetamol available in the market (Panadol®, Tylenol®, Calpol® etc). Instructions on the pack should always be read and followed strictly before taking or giving a dose to children.

2) Non-steroidal anti-inflammatory drugs (NSAIDs)

Aspirin and other NSAIDs inhibit cyclooxygenases leading to a decrease in prostaglandin production. Besides reducing pain and fever, NSAID also reduces inflammation. It is commonly used to relieve muscular pain and arthritis. Its most common side effect is gastric irritation, which can be alleviated by taking it with food or after food. The doctor may prescribe an NSAID with an antacid for certain group of patients eg the elderly who are at increased risk for upper gastrointestinal adverse events. NSAIDs also predispose patients to peptic ulcers, renal failure, allergic reactions and increase risk of bleeding by affecting platelet function. Some examples of NASIDs include Mefenamic acid (Ponstan®, Fengesic®, Pontalon®), Ibuprofen (Brufen®, Nurofen®), Diclofenac (Voltaren®), Piroxicam (Feldene®), Naproxen (Synflex®), Indomethacin (Indocid®) and others.

3) Cyclooxygenase-2 or COX-2 inhibitor

COX-2 inhibitors are derived from NSAIDs. It was developed to inhibit only COX-2 enzymes in contrast to NSAIDs which inhibits both COX-1 and COX-2. The COX-2 inhibitors are equally effective analgesics when compared to NSAIDs but cause less gastrointestinal bleeding in particular. However, the role of this class of drug is debated with post-marketing data, which indicated increased risk of cardiac and cerebrovascular events associated with these drugs. This led to the world-wide withdrawal of Rofecoxib from the market. COX-2 inhibitors remain an alternative analgesic but are more costly. Some examples are Celecoxib (Celebrex®) and Etoricoxib (Arcoxia®).

4) Opiates and Narcotic drugs

Morphine, Codeine (opium alkaloids), Oxycodone (semi-synthetic), Pethidine, Fentanyl and Tramadol (fully synthetic opiods) are all narcotic drugs and they all exert similar influence on the cerebral opiod receptor system to reduce sensation of pain.

Opiods are very effective strong analgesics for relief of severe or chronic pain but with some unpleasant side effects. Up to one in three patients starting morphine may experience nausea and vomiting. Pruritis (itching) may require switching to a different opiod. Constipation occurs in almost all patients on opiods and laxatives are commonly co-prescribed. Dosing of all opiods are limited by opiods toxicity such as respiratory depression, confusion, depression, myoclonic jerks and pinpoint pupils. Interestingly, there is no upper limit for the dosage of opiods used to achieve pain relief, but the dose must be increased gradually to allow for the development of tolerance to adverse effects.

Opiods when used appropriately are otherwise safe and effective. Risk of addiction and tolerance can occur when the body becomes used to the drug and dosing may need to be increased to achieve similar analgesia as before. Although there is no upper limit or ceiling dose, there is still a toxic dose even if the body has become used to higher doses.

5) Combination analgesics

Analgesics are frequently used in combination, such as paracetamol and codeine preparations found in many pain relievers eg Panadeine®, Migraleve® and Norgesic® Paracetamol can also be found in combination with decongestant and / or antihistamine in cold and flu medicines.

One can accidentally take more than the recommended daily dose by taking multiple drugs, which contain paracetamol. Therefore, avoid taking two or more products containing the same medicine at the same time.

The use of paracetamol, as well as aspirin, ibuprofen, naproxen and other NSAIDs concurrently with weak to mid-range opiates have been shown to have beneficial synergistic effects by combating pain at multiple sites of action - NSAIDs reduce inflammation while opiates dull the perception of pain.

6) Topical analgesics

Topical analgesics (cream, ointment, rubbing oil) are generally recommended to avoid systemic side effects. Painful joints may be treated with an ibuprofen, diclofenac, capsacin or salicylates topically.

7) Atypical and / or adjuvant analgesics

Orphenadrine, scopolamine, atropine, gabapentin, first generation antidepressants eg. Amitriptyline and other drugs possessing anticholinergic and / or antispasmodic properties are used in many cases along with analgesics to potentiate centrally acting analgesics such as opiods. Dextromethorphan has been noted to slow the development of tolerance to opiods and exert additional analgesia.

CONCLUSION

Analgesics are very effective medicines when being used appropriately according to the recommended dose and instructions. Many analgesics are available over-the-counter and many contain combination ingredients in them. Caution must be exercised to avoid taking multiple preparations containing the same analgesic that can lead to an overdose. Under all circumstances, over the counter analgesics that can be purchased from the shops should only be used for short-term (3 - 5 days) relief. If your symptoms do not go away in this time, see your doctor immediately.

Source: Weekend 11 July 2009

Smoking: Dying for a cigarette

By

the Health Education and Promotion Division,

Ministry of Health

"Smoking is bad", it stains your teeth, causes premature wrinkles, makes your hair and clothes smell, lowers your physical stamina and on top of all that, it's a waste of money. In fact, if you are a smoker, you have a 25 per cent chance of dying before the age of 60.

Globally1.25 billion people or one-fifth of the world's population are smokers.
Smoking causes 25 different life-threatening diseases and is responsible for one-third of all cancer disease. It is also a major contributor to the development of bronchitis, asthma, high-blood pressure, increased cholesterol, heart attack, diabetes, and infertility.

This is a major concern as current trends predict that in the next 30 years, over 100 million people will die from tobacco related illnesses exceeding the death toll from AIDS, tuberculosis, automobile accidents, maternal mortality, homicide and suicide combined. (WHO, World Health Organization).

In an attempt to control tobacco use, many countries have implemented taxes, raised warnings and put up laws to control the sale and consumption of tobacco. While the changes in policy and legislation have been successful in reducing the number of smokers, 72 per cent of all smokers still live in developing nations and this number is expected to rise to 85 per cent by 2025. Tobacco is a silent killer and 500 million of all the people alive today will die because of this deadly habit.

What's in a cigarette?
Cigarette tobacco typically contains 1-3 per cent nicotine. When tobacco is burnt, nicotine is vaporised and enters the smoke, attached to tiny particles of tar. About 40 per cent of cigarette smoke is tar. Inhaled smoke carries the mixture of tar and nicotine deep into the lungs where 90 per cent of the nicotine is readily absorbed into the bloodstream.

There are many ingredients in tobacco smoke especially in the tar, in which over 4,000 thousand chemical compounds have now been detected, 43 of which are proven to cause cancer.

The contents of the smoke depend on the type of tobacco and the way it is burnt. The last third of the cigarette produces more tar and nicotine then the first two thirds together. Filter cigarettes first introduced in the 1950's have about 60 per cent of the tar yield of non-filter cigarettes.

In addition to the many organic chemicals in tobacco smoke there are also various gases such as carbon monoxide and other biologically active gases (such as oxides of nitrogen and hydrogen cyanide), and various heavy metals, including cadmium and lead, some of which are present in radioactive form. Some of these ingredients of smoke act locally, in the mouth, throat, larynx, trachea or lungs, where they are deposited. Others are absorbed from the mouth or lungs into the bloodstream and may then act on tissues throughout the body.

The four major components of tobacco smoke

1. Nicotine: Has many pharmacological actions, especially as a cardiovascular stimulant and within the central nervous system. It affects the body's metabolism and increases the concentration of high density lipids (bad cholesterol) and glucose in the blood. Nicotine is one of the most powerful poisonous substances known; an injected single drop causes death within a few minutes.

2. Cancer producing substances (Carcinogens): The occurrence of cancer is increased by factors that predispose or promote development during the stages of carcinogenesis. Since cigarette smoke is a rich chemical cocktail, containing about 60 known or suspected carcinogens it is no surprise that smoking seems to affect all stages of cancer development. Some of the chemical substances found in cigarette smoke include tar, arsenic, ammonia, methanol, arsenic, lead, mercury and cyanide, most of which are well known poisons.

3. Irritant substances: An immediate effect of inhaling tobacco smoke is constriction of the bronchial tubes. Regular smoking impairs the action of the cilia lining the bronchial tube. These hair like cilia normally move in a coordinated fashion to clear mucus secretions up into the throat; inhaled dust and bacteria are thus continually removed from the healthy lung. Smokers have to rely on their 'smokers cough' as a substitute for this normal self-cleaning mechanism. The cells lining the lungs and throat are unable to function properly as the chemicals found in the tobacco smoke paralyse them.

4. Carbon monoxide and other gasses: Upon absorption into the blood, carbon dioxide (CO) attaches rapidly and tightly to the red blood cells and thus preventing the amount of oxygen available to the body. Smokers on one pack a day have twice the normal amount of carbon dioxide in their blood throughout most of the day. Carbon dioxide is a toxic gas and a lack of available oxygen will increase the risk of circulatory diseases.


Benefits of Quitting

If you are a smoker and thinking about quitting, remember your body will benefit the minute you stop;

In 2 hours- nicotine will not be present in the blood.

In 6 hours- your heart rate and blood pressure will reduce slightly.

In 12-24 hours- the body will release Carbon Monoxide and your stamina will improve because increased lung efficiency.

In 2-3 days- You will feel fresher and your sense of taste and smell will greatly improve.
In a few days after- Your respiratory systems cleaning mechanism has begun to re-activate itself, you will notice increased phlegm when you cough.

In 3 weeks time- Your lungs are functioning better and exercise is getting easier.

In 2 months time- Circulation in your body organs and extremities has greatly improved and you begin to experience a feeling of overall well-being.

In 3 months time- Your lungs are now functioning normally, sperm production has resumed to normal levels and there are fewer mutations. The risk of infertility for males has gone down.

In 12 months time- The risk of dying suddenly as a result of heart attack or stroke has been reduced by 50 per cent less than those still smoking.

In 5 years time- The risk of death as a result of heart attack or stroke is now the same as a person who does not smoke.

In 10-15 years time- The risk of dying from diseases such as lung cancer is now the same as a person who has never smoked.


10 steps to "Quit Smoking"

Congratulations for making a positive choice, below are a few steps that can help you become tobacco free.

Step 1: Be specific by deciding how you want to quit. You can stop smoking immediately or by gradually reducing the number of cigarettes. Choose a specific date and reduce the number of cigarettes smoked a few weeks in advance if you plan to stop immediately.

Step 2: Get support from your friends and family, try to get a few friends to quit with you. Get your friends who smoke to co-operate by not smoking near you or to tempt you with cigarettes.

Step 3: Throw away all cigarettes and smoking implements such as lighters, pipes, ash trays and anything else you associated with smoking.

Step 4: Take one day at a time and praise yourself every time you overcome an urge to smoke.

Step 5: Think Positive. Believe that you are someone who does not smoke and if someone offers you a cigarette tell them, 'No thank you, I don't smoke'. Remember you can choose not to smoke.

Step 6: Fight the temptation to smoke, As a person who has just stopped smoking you will feel irritated, anxious, angry and sometimes vulnerable, all of which are withdrawal symptoms of nicotine. These symptoms will only last a few weeks and remember that every time you succeed in not smoking you are one step closer to becoming tobacco free.

Step 7: Save all the money you normally use to buy cigarettes and use it to buy yourself something special when you are truly free of tobacco. This will normally take anything from 6 months to a year.

Step 8: Watch your figure, an increase of body weight may be experienced because your appetite is not suppressed anymore. Eat food that is low in carbohydrate and drink lots of water. Exercising 30 minutes a day can help keep you fit and trim. Exercise will not only make you look better but can also distract you from the temptations of smoking.

Step 9: Get professional help, if needed, meet with your doctor to get some advice and a check-up at the same time.

Step 10: Don't give up if you fail. If you fail try and try again. Remember there are no benefits from smoking and it is a danger to your health.


Commonly asked questions:

Quitting is not easy and the only way to stop is to not give up. Many of the people who try to stop smoking are faced with many challenges, below are some of the answers to commonly asked questions:

1. Won't I gain weight if I stop smoking?

Not everyone who stops smoking gains weight.
Average weight gains are small for people who do gain (2-5kg).
Don't diet now- there will be time once you are an established non-smoker.
Exercise is an effective technique to cope with withdrawal and to avoid weight gain.
Avoid high calorie snacks. Vegetables and fruits are good snacks.
The health risk of smoking is far greater then the risk gained from a small weight gain.
A small weight gain will not hurt your appearance. Smoking causes yellow teeth, bad breath, stale clothing odour and possibly wrinkled skin.

2. I don't have the willpower to stop smoking.

More then 3 million Americans break their nicotine habit every year.

Not everyone is successful the first time but many people are successful after several attempts.

Gain support from family and friends, inform your friends and family that you have stopped smoking. Better still get your friends who smoke to quit with you.

3. I only smoke low tar/ light cigarettes, so why should I stop?

There is no such thing as a safe cigarette.

Most smokers just inhale deeper or more frequently to compensate for low nicotine level in these cigarettes.

4. Is it better to stop cold turkey or over a period of time?

There is no "best way"

Most successful former tobacco users stop "cold turkey" (stopping immediately and not touching a single cigarette).

5. What about insomnia?

Many tobacco users report having problems sleeping after they stop. If these symptoms are related to nicotine dependence they should disappear within 2 to 3 weeks.

6. Why do I cough more now that I've stop smoking?

About 20 per cent of former smokers report an increase in coughing after they stop. This is a temporary response thought to be caused by an increase in the lung's ability to remove mucus, so it actually represents recovery of the lungs defence mechanism.

7. Now that I've stopped can I use tobacco occasionally?

No, Nicotine addiction seems to be triggered quickly in most former users. Don't risk becoming hooked again.

8. Will my body recover from the effects of smoking?

Some of the damage may be permanent, such as loss of lung tissue in emphysema.
Other functions are recovered, such as the lungs ability to remove mucus.

The increased risk of heart disease is halved in the first year and approaches that of non-smokers in about 5 years.

The increased risk of lung cancer diminishes and approaches that of a non-smoker in 15 to 20 years.

9. Should I tell people I'm trying to stop?

Yes, you should enlist the support of family, friends and co-workers.

10. What should I do if I get the urge to smoke?

Some people relieve cravings by chewing sugar free gum, sucking on a cinnamon stick, or eating a carrot stick.

Craving for cigarettes are a normal part of withdrawals.

Most cravings last for only a few minutes and then subside.

Cravings become rare after a few weeks.

Use nicotine gum if prescribed.

11. When I don't use cigarettes, I feel restless and can't concentrate.

These are normal symptoms of nicotine withdrawal.

These symptoms are most acute in the first 3-4 days after stopping.

These symptoms will disappear after a few weeks.

12. What other withdrawal symptoms will I have?

Some people will have few or no symptoms of withdrawal.

Other common symptoms will include anxiety, irritability, mild headache and gastrointestinal problems such as constipation.

A few people experience all of these symptoms.

Like other symptoms, they are all temporary.

13. I'd like to use nicotine gum, but I'm afraid I'll become addicted to it.

A small percentage of people do use nicotine gum for longer then 3-6 months recommended.

Most people are able to gradually reduce without discomfort the amount of nicotine gum they use, until they stop completely.

Nicotine gum does not damage the lungs or the lining of the mouth and nicotine itself is not known to cause cancer, so it is less harmful then smoking or using smokeless tobacco. Tobacco contains many dangerous chemicals.


Overcoming the mental challenges of quitting

If you experience any of the following;

1) Unable to concentrate

Take a short break.
Get out of the office and go for a short walk.
Lighten your workload a few days after you quit smoking.
Do light exercise.
Share your feelings with your family or friends.

2) Unable to sleep

Avoid drinking coffee or caffeine based drinks.
Exercise so that you will feel tired and sleep easily.

3) Difficulty waking up in the morning

Take short naps during the day if needed.
Go for a walk in the morning.
Change your daily routines.

4) Feeling anxious or depressed

Begin doing exercise you enjoy or have always wanted to learn how to do.
Take up a hobby that you enjoy.

Steps you can take if you are offered a cigarette.

Refuse politely so that you do not offend anyone.

If you feel pressured, give an excuse and leave the place or avoid the person offering cigarettes.

Inform your friends that you have made a decision to quit smoking and that you have a desire to quit.

Remind yourself why you want to quit and what benefits you will gain from quitting.

Good luck!

Remember, don't give up and try again if you fail the first time.

Source: Weekend, June 20, 2009

TB: Common yet fatally infectious

By

Dr Hjh Salizawati bt Mohd Zainal,

Senior Medical Officer,

National Tuberculosis Coordinating Centre, Kiarong

A boy pouring water as villagers collect their own from a lake in the village of Thamada, Myanmar. In 2006, there were 9.2 million new cases of symptomatic tuberculosis and three million deaths from the disease. AFP

Introduction
Tuberculosis or TB (short for tubercle bacillus) is a common yet dangerous infectious disease caused by airborne mycobacterium tuberculosis.

The disease has been a serious public health problem and in the early 19th century, the disease caused more than 30 per cent of all deaths in Europe.

With the advent of anti-tuberculosis drugs in the late 1940s, the battle against tuberculosis seemed to be won.

Unfortunately, in the 1990s, the world faced another threat against tuberculosis with the emergence of drug resistance tuberculosis, the escalation of HIV/AIDs rates, extreme poverty in many parts of the world and hence tuberculosis continues to be a deadly disease worldwide.

In 2006, there were 9.2 million new cases of symptomatic tuberculosis and three million deaths from the disease. And of the 9.2 million new cases, about three million occurred in Africa, three million in Southeast Asia, and about two million in Western Pacific region.
India and China reported the largest total number of new cases, but South Africa had the highest rate of new cases in the world, with 940 new cases per 100,000 people.

In Brunei Darussalam, it was reported in 2008 that there were 223 cases of TB where majority are pulmonary TB.

How Infection Develops
People can be infected with tuberculosis only from a person who has active disease.
The bacteria are spread almost exclusively through the air.

People with active tuberculosis in their lungs often contaminate the air with bacteria when they cough, sneeze, or even speak.

These bacteria can stay in the air for several hours. If another person breathes them in, that person may become infected. Thus, people who have contact with a person who has active tuberculosis (such as family members or health care practitioners who treat such a person) are at increased risk of getting the infection.

In most cases, tuberculosis bacteria that enter the lungs are immediately killed by the body's defences.

Those that survive are engulfed by white blood cells. The engulfed bacteria can remain alive inside these cells in a dormant state for many years (this stage is called latent infection).

In 90-95 per cent of cases, the bacteria never cause any further problems, but in about five-10 per cent of infected people, they eventually start to multiply and cause active disease especially in a person with impaired immune system - for example elderly, person with HIV/AIDs, the use of corticisteroids, person with chronic disease such as diabetes.
Tuberculosis primarily affects the lungs (80 per cent) but can also affect other parts of the body like the bones, skin, lymph nodes, gastrointestinal system and other organs.

Symptoms & Complications

Prolonged cough more than two-three weeks, is the most common symptoms of tuberculosis especially pulmonary tuberculosis.

The cough may produce a small amount of green or yellow sputum in the morning.
Eventually, the sputum may be streaked with blood.

Rapidly developing shortness of breath plus chest pain may also be symptoms of pulmonary tuberculosis.

People may awaken in the night and be drenched with a cold sweat, with or without fever.
People also feel generally unwell, with decrease energy and appetite. Weight loss often occurs.

Diagnosis
When people have symptoms that suggest tuberculosis, the following may be done: Chest x-ray; tuberculin skin test; blood tests; and microscopic examination and culture of sputum sample and other suspected specimens.

The sputum and other suspected specimens are examined under the microscope to look for tuberculosis bacteria and are used to grow bacteria in a culture.

Microscopic examination provides results much faster than a culture but is less accurate. It detects only half the cases of tuberculosis identified by culture.

However, traditional cultures do not provide results for many weeks because tuberculosis bacteria grow slowly. For this reason, treatment of people who may have tuberculosis is often begun while doctors wait for results of culture.

Treatment

People who are diagnosed with active tuberculosis are required to take medications to kill the bacteria.

The most commonly used anti-TB treatment are isoniazid, rifampicin, pyrazinamide and ethambutol which are taken orally.

Streptomycin is sometimes added to the regimen.

All of these drugs have side effects, but 95 per cent of people with tuberculosis are cured and do not experience any serious side effects. Because tuberculosis bacteria are very slow-growing, anti-tuberculosis treatment must be taken for a long time - usually six months (the first two months, four different types of anti-TB treatment are taken daily followed by continuation phase, two different types of anti-TB treatment are taken thrice weekly).

To avoid poor compliance, the World Health Organisation (WHO) has recommended implementation of DOTS.

What is DOTS?
DOTS or Directly Observed Treatment Short-Course has been the internationally recommended strategy to control TB since the early 1990s.

DOTS aims to decrease TB-related morbidity, prevent TB deaths, decrease TB transmission and avoid the development of drug-resistant TB.

Patients undergoing DOTS therapy will be observed by a medical professional or a trained supervisor while they take medication.

This ensures that the correct dosage of the drug is taken at the right time and also to be certain that patients do not vanish partway through treatment.

There are five elements of DOTS:
- Political commitment with increased and sustained financing;
- Case detection through quality-assured bacteriology;
- Standardised treatment with supervision and patient support;
- An effective drug supply and management system, and;
- A monitoring and evaluation system, impact measurement span.

Since 2000, Brunei Darussalam has implemented DOTS and the DOTS coverage has been 100 per cent in all the four districts. Each health centre has a trained DOTS medical personnel to supervise patients with tuberculosis while taking their anti-TB treatment.

Prevention
There are two aspects of prevention of TB: stopping the spread of infection; and treating early infection before it becomes active disease.

Stopping the spread of infection

Allowing good ventilation with fresh air will lower the concentration of bacteria and limits their spread. Also, allowing sunlight to enter houses can kill airborne tuberculosis bacteria.

Visitors visiting TB patients in the ward should wear masks to prevent them from getting infected by the bacteria.

Healthcare workers who handle samples of infected tissue or interact with people who may be infected with TB should also wear masks to help protect them.

People with active tuberculosis especially those with pulmonary TB need to be isolated such as in isolated ward, to reduce the spread of the airborne tuberculosis bacteria and they are also required to wear masks during isolation.

Treating early infection
People who have close contact with TB patients (especially pulmonary TB) will need to go for tuberculin skin test to find out whether they are infected with tuberculosis bacteria. And if they have positive tuberculin test (that is, latent TB infection), they should be treated with drugs that will prevent them from developing into active TB disease.

Isoniazid is very effective at stopping the infection before it becomes active disease. It is given daily for six to nine months.

Administration of BCG (Bacille Calmette-Guerin) vaccine at birth has been practiced in some countries especially in countries where the likelihood of contracting tuberculosis is high.

It is given to prevent development of serious complications among children, such as meningitis.

Conclusion
Tuberculosis is one of the oldest diseases known. In most countries, tuberculosis is stigmatised, and many people are reluctant to believe that they even have latent infection.
Individuals who have symptoms of TB are advised to seek for further examination at the nearest health centres.

Tuberculosis is curable but it can be fatal if left untreated.

Ministry of Health Public Awareness Programme

Source: Weekend, 9 May 2009

Now you see, Now you don't - Glaucoma, the silent blinding eye condition

By

Dept of Ophthalmology,

RIPAS Hospital

Blind Indonesian students playing chess inside their room at a rehabilitation centre in Jakarta, Indonesia. According to the World Health Organisation, more than 161 million people are visually impaired worldwide; among them some 124 million have low vision and about 37 million are blind. Another 153 million people suffer from visual impairment due to uncorrected refractive errors. More than 90 per cent of the world's visually impaired people live in low- and middle-income countries. The most common causes of blindness all over the world are cataract, glaucoma, cornea disorder, macula degeneration and diabetic retinopathy. epa

Courtesy of WHO

Glaucoma is a spectrum of related diseases. Increased pressure in the eye is a measurable problem in this disease. Increased pressure can occur due to a variety of reasons. When the pressure in the eye is high it can cause damage to the optic nerve, which transmits visual information from the eye to brain.

Glaucoma is the second most common cause of blindness worldwide, where 4.5 million persons globally are blind due to glaucoma and is expected to rise to 11.2 million by 2020. Up to 90 per cent of affected persons may not even aware of having the disease.

Glaucoma affects more than 4.5 million people worldwide of whom 10 per cent or 6.6 million people are blind. Glaucoma is the leading cause of irreversible blindness and is second only to cataract as the most common cause of blindness.

The prevalence of glaucoma in Southeast Asia (Singapore) is 4.7 per cent. No population-based data of glaucoma prevalence in Brunei Darussalam is currently available. However, extrapolating the prevalence in the region, about 13,000 should have glaucoma. But studies have shown that 50 per cent of glaucoma remains undiagnosed and at least 10 per cent of the people are blind in one eye at the time of diagnosis .It is commonly seen after 40 years of age and the chance of getting the disease increases with advancing age.

The inheritance of glaucoma still remains obscure. Family history of glaucoma can be seen in 50 per cent of the relatives in one kind of glaucoma. Trauma to the eye can also cause glaucoma.

There are certain groups of people who have increased risk of developing glaucoma; people with diabetes, myopia (short-sightedness), old age, small eyes, family history of glaucoma, migraine, high blood pressure and severe acute low blood pressure. These high-risk people should be evaluated early at the age of 40 and at regular intervals thereafter.

The fluid inside the eye is called the aqueous humor, which is formed by specialised cells. This fluid maintains the pressure normally up to 21mm Hg in normal eyes. This fluid is necessary to carry the nutrients to important structures and removes waste products. The fluid moves out of the eye through small channels to the blood circulation. When the normal flow of the fluid gets blocked the pressure inside the eye can build up causing damage to the optic nerve.

Damage to the optic nerve can cause blind areas in the outer side of vision, which is the beginning of the damage. As the disease gets worse only the central tunnel of vision remains. What is common to all glaucoma is the visual loss that cannot be reversed. Hence early diagnosis and management is very important.

There are two types of glaucoma - open angle and closed angle. In open angle glaucoma the normal drainage channels of the eye is anatomically open but does not function normally. When the fluid cannot leave the eye, the pressure builds up and eventually causes vision damage. This causes painless, progressive loss of vision that may escape the patient's attention. In angle closure glaucoma the site from which the fluid leaves the eye is narrow or physically blocked. This can occur suddenly, which causes a painful red eye with general symptoms such as vomiting. This is due to a rapid increase in eye pressure.

The cornerstone of management of glaucoma is detecting it at the earliest possible stage. People at risk should undergo annual eye examinations. The diagnosis of the problem is made by a comprehensive eye examination with special attention in estimating eye pressure, estimating field of vision and evaluation of the eye's optic nerve and visualising the drainage angle.

The eye pressure is measured by instruments called a tonometer. This can be non-contact where a jet of air is used to estimate the pressure or contact, where the doctor uses a special instrument, which touches the eye to measure the pressure. The latter is more accurate. The upper limit of eye pressure is set at 21mm of Hg. If the pressure is more than this on three consecutive separate visits, the suspicion of glaucoma arises. At times the doctor will estimate pressure at various times of the day to confirm that the pressures are elevated.

The optic nerve is assessed by examining the back of the eye with special lenses and a microscope. Increased pressure damages the nerve fibres, which can cause excavation of the optic nerve seen clinically as cupping, signifying the cumulative damage of individual nerve fibres. These changes are now recorded with digital cameras and archived for reference at subsequent assessment to monitor progression. There are many modern instruments such as optical coherence tomogram, nerve fibre layer analyser, which can exactly quantify the glaucomatous damage to the optic nerve.

The field of vision is estimated with a perimeter. The exact site and amount of the defect is measured with computer-assisted programmes and stored for comparison overtime.

The 'triad' of increased pressure, nerve damage and the loss of fields form the syndrome of glaucoma. At times only the eye pressure is elevated without associated corresponding changes in the field of vision or nerve changes. This is known as ocular hypertension and is such that a person's eyes need careful follow up examinations. Diagnosis of glaucoma is made if at least two of these three criteria are present.

The primary aim of treatment is to preserve the existing vision for as long as possible. The typical first line of treatment is the use of eye drops, which lowers the eye pressure by helping the fluid leave the eye or by reducing the amount of fluid produced in the eye. Some people need to take different combinations of eye drops depending on the extent of damage. The drops have to be applied as prescribed by the doctor paying attention to the time schedule. The eye medications do not cure the disease. They lower the pressure to prevent further damage and therefore must be used

continuously to maintain the pressure at a level, which has been decided by the doctor, much like medications to lower blood pressure in hypertension.
In addition there are laser treatments for both open angle and angle closure glaucoma. laser trabeculoplasty is generally done for open angle glaucoma that continues to progress despite use of medications. A laser beam is directed at the outflow channels to increase the fluid drainage. The procedure is done as an out patient procedure at the eye doctor's office. Laser treatment does not cure glaucoma. It helps to lower the eye pressure, which can either stop or slow down vision loss. Laser treatment is also done for angle closure glaucoma. This is called as laser iridotomy, which is done to eliminate the mechanical blockage by diverting the fluid. A small opening is made in the iris (the coloured part of the eye). The iris falls back to open the angles thereby removing the mechanical blockage to fluid egress resulting in lowered pressure.

All laser procedures have some risks and are not done unless the benefits outweigh the risks.

Source: Weekend, 25 April 2009

Swine Influenza and You

What is Swine Influenza?
Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.

Is it contagious?
Swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.

What are the symptoms?
The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

How does swine flu spread?
Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

For more details please visit http://www.cdc.gov/swineflu/swineflu_you.htm

Stress in children and adolescents

By

Dr Abang Bennett Taha

Specialist Psychiatrist (Child and Adolescent)

RIPAS Hospital, Bandar Seri Begawan

A Palestinian student looks out the window of a classroom. At school, factors that may cause stress include starting school, change of school, high expectations, bullying by peers or other schoolmates, and punishment by teachers. Pressure from studying is the most common cause of stress in children and adolescents. epa

In modern society stress is inevitable. Stress arises when an individual perceives that he cannot adequately cope with the demands being made of him or when his well-being is threatened.

The worst possible way to cope is to run away from it or avoid dealing with it. If an individual is constantly stressed, he will be in danger of developing long-term stress-related physical illness or more importantly it could trigger a mental breakdown.

This article will initially discuss stress in general and then specifically focus on stress in children and adolescents. We will then deal with approaches for both parents and teachers to help their children or students who are stressed.

Is stress bad?
The answer is both 'yes' and 'no.'

If we have no stress in our lives, we would probably be dead. With little or no stress, we would not be motivated to perform. As stress increases, our performance will also increase until it reaches an optimum level of functioning.

Further increase in stress after this optimum level will not, however, increase the performance but will plateau off until the stress level becomes distress.

At this point, further increase in stress level will cause the performance to decline. Stress is therefore both useful and bad depending on the intensity of the stress experienced.

What causes an individual to feel stress may not affect another. A lot depends on the personality, attitude and expectation of life. The challenge is for the individual to determine what level of stress he needs to function at his optimal level.

Can children and adolescents experience stress?
The adolescence period is the most stressful time in a young person's life. This is the time when children change or grow up into adults. They are going through puberty, meeting the changing expectations of others and coping with feelings that may be new to them. Children too cannot avoid stress. The sources of stress may be personal, from the home, and the school.

Personal sources
Personal sources include high hopes, unrealistic values, fear of failure and comparing himself to his siblings or other children.

Children and adolescents who have impaired intellectual ability, especially mild intellectual impairment, are vulnerable to experiencing stress when their disability is not recognised by their parents or teachers.

Home
At home, entry and exit events can be very stressful to both children and adolescents. The birth of a sibling is very stressful to a child or even an adolescent, which may lead to emotional or behavioral problems.

To a young child, the younger sibling is his rival. An adolescent may feel ashamed when his mother gives birth to a sibling.

Parental conflict, where there are lots of quarrel and violence at home, is the worst stressors that a child or adolescent can experience. Divorce by itself is harmless but becomes stressful when there is a fight for custody of the children or when the parent who has custody is neglecting the child.

A divorce may help young people recover from the 'trauma' of being caught in the dysfunctional family environment. An intact family with calm environment is the best environment for young people to nurture and this is what we should achieve.

Not being able to fulfil the demands of parents is another source of stress at home. Please remember that young people have their limits and each individual is different. Expecting all young people to respond to our demands in the same manner can lead to disaster.

School
At school, factors that may cause stress include starting school, change of school, high expectations, bullying by peers or other schoolmates, and punishment by teachers. Pressure from studying is the most common cause of stress in children and adolescents.

Teachers should be able to recognise the early signs of stress in young people. They and the school management should provide a suitable environment for young people to learn and nurture rather than expecting young people to 'digest' whatever has been taught, or at the other extreme, ignoring young people when they cannot learn as expected.

Young people with special needs can go into 'catastrophic reaction' if they are stressed in the mainstream environment. They should not be ignored but should instead be given the support throughout the time they are at school.

Young people with borderline problems (ie those who appear normal but just cannot learn as much as their peers) are the most stressed individuals in the school scene. They are usually labeled as lazy or their parents are considered to be paying no attention to their educational needs.

Reaction to stress in children and adolescents
This depends on the developmental stage of the child, ability to handle stress, duration and intensity of the stress and support that is given. In early childhood, they may feel unloved, becoming clingy and demonstrating a dependent behavior.

Children in the middle childhood stage may show fearfulness, defiant behaviour, complain of headaches and sleep problems or observed to have poor concentration at school.

Adolescents on the other hand will demonstrate it with anger, hysterical behavior, disappointment, low self esteem and loss of faith in adults. In extreme cases, adolescents may indulge in health risk behaviours such as deliberate self-harm, violence, substance use, risky sexual behaviour and unhealthy dietary behavior.

Before we discuss the approaches to handling stress, let us examine the following cases.

Case 1
Armah was actually the kind of daughter any parent would be proud of. She studied hard, was obedient and a devout Muslim. She had a few friends and spent all her free time looking after her younger siblings.

Her father had very high expectation of her, wanting her to excel in her 'O' Level examinations. Armah felt so pressured to do well in her examination that when the day arrived, her mind was a blank.

She had so wanted to make her parents proud. She was devastated when she failed the exam. Her father was angry, blaming her for not studying hard. She felt worthless and a disgrace to her family. Impulsively she took 20 Panadol tablets.

Case 2
Ali, a Primary I pupil, cries when he wakes up in the morning, complaining of stomach ache and refusing to go to school. This happens everyday, consecutively. The doctor who treated him could not find any physical causes for the problem.

Earlier, his mother had spent a lot of time forcing him to focus on his 'Spelling' subject as she was expecting him to score 100%.

He scored poorly and was admonished by his teacher. When he returned home, his mother also scolded him.

Case 3
A Form III girl was punished by her teacher in the presence of her classmates for not handing in her assignment according to the required format.

She had told her father to buy the materials from the shop earlier but he could not effort to buy them. The next day she was not her normal self and started to scream and going berserk when she was in the toilet.

The other students nearby attempted to calm her down but she was strong. One of the students who tried to help her also started to scream.

These three cases show the various types of reaction to stressful situation. All the situations depicted above happen in our real life and the experiences encountered by the children are perceived as stressful leading to maladaptive reactions.

Children and adolescents should enjoy studying rather than pressured to do so. Sometimes children have limit to their learning ability, therefore parents and teachers should have realistic expectations regarding their ability.

In case 3, it was the family's financial difficulties that caused the girl not adhering to the regulation.

In this situation simple financial help and the teacher's understanding of the girl's problems removed the maladaptive behaviour. We must always remember that social problems in our community are the reactions of young people to stressful situation that occur at home, at school or both.

How can we help stressful young people?
Keep talking to them: Everyone needs to be able to talk and listen to others. If it stops happening, problems and misunderstanding creep in. Keep the communication lines open.

Listen to them: Being able to listen is a key aspect of good communication.

Good listening means:
- showing you are attentive
- trying to understand what they are saying to you
- taking time to find out about their views and feelings without arguing with them
- not insisting on our views being heard all the time; listen to their views as well.

Put ourselves in their shoes

It will help if we can show that we do understand what it's like for them. It means showing them that we are sensitive to their problem. We have to try to look at the world through their eyes.

Be there and be available
It is important that young people know the door is always open for them to talk to us. They want to feel we are always interested in them. Sometimes, unfortunately, we are physically, but not emotionally present.

Be firm but consistent
Make sure our views and feelings are known and that we want them to respect our views. Be consistent as well. Do not keep changing your mind or making threats that you won't carry out. We must differentiate firmness from anger.

Remember young people are unique
Children have strengths and they all need to feel valued and good about themselves. When they feel they can achieve something, and that we recognise what they have done, it helps to build their self esteem.

What to do when the above approach is not helpful?
When the above approach is not helping young people or when the stress led to serious psychiatric complications it is important that the child or adolescent is referred to the mental health professionals.

Who are the mental health professionals who can help them? A child and adolescent psychiatrist or a clinical psychologist may be able to help.

A child and adolescent psychiatrist is a medical doctor who has further training in the diagnosis and treatment of mental health problems in young people.

They use both medicine and psychological techniques in helping these young people.

Clinical psychologist is not a medical doctor but they learn about both normal and abnormal human behavior. In addition they have further clinical training in the treatment of people with mental health problems using psychological techniques.

Sometimes we use antidepressant if young people become depress. For the very young psychological methods are best.

These include parents' management training, behavior modification, cognitive behavior therapy and workshop for teachers.

Source: Weekend, 18 April 2009

Understanding autism

By

Malai Haji Abdullah bin Malai Haji Othman

Senior Nursing Officer

Ministry of Health

There is no theory of the cause of autism which everyone has found convincing. There may be multiple causes. Thus we will review some of the proposed causes.

Most researchers are absolutely convinced that the cause is biological rather than psychological.

Bernard Rimland in his book, "Infantile Autism", cited the following evidence for a biological genesis and against the idea that parents cause their children to be autistic:

- Some clearly autistic children are born to parents who do not fit the autistic parent personality pattern.
- Parents who do fit the description of the supposedly pathogenic parent almost invariably have normal, non-autistic children.
- With very few exceptions, the siblings of autistic children are normal.
Autistic children are behaviourally unusual "from the moment of birth".
- There is a consistent ratio of three or four boys to one girl.
- Virtually all cases of twins reported in the literature have been identical, with both twins afflicted.
- Autism can occur or be closely simulated in children with known organic brain damage.
- The symptomatology is highly unique and specific.
- There is an absence of gradations of infantile autism which would create "blends" from normal to severely afflicted.

Points four and nine are not generally accepted now, perhaps because of the broadening of the condition's definition over time, and perhaps because of additional observation & data collection.

There is still controversy over neurological differences in the brains of autistic people and the rest of the population.

However, it does appear from evidence obtained through autopsies, MRI and PET scans that there are subtle cellular changes in the autistic brain.
The increased incidence of seizures (20-30 per cent develop seizures in adolescence) also points to neurological differences.

Some specific theories as to the cause of autistic symptoms:
- Yeast infections.
- Intolerance to specific food substances.
- Gluten intolerance ("leaky gut syndrome"), casein intolerance causing intestinal permeability and allowing improperly digested peptides to enter the bloodstream and cross the blood-brain barrier which may mimic neurotransmitters and result in the scrambling of sensory input. I've also heard "Leaky Gut Syndrome" described as lack of the beneficial bacteria that aids digestion, and that the resulting matter in the bloodstream invokes an unnecessary immune reaction.

Phenolsulphortransferase (PST) deficiency theory that some with autism are low on sulphate or an enzyme that uses this, called phenol-sulphotransferase-P. This means that they will be unable to get rid of amines and phenolic compounds once they no longer have any use for them. These then stay in their body and may cause adverse effects, even in the brain. Treatment is dietary as well as epsom salts baths.

A phrase you will sometimes hear is "theory of mind" or "the theory of mind hypothesis". This is not so much a supposed cause of autism as an assertion as to its nature. The basic idea of the hypothesis is that autistic people lack an awareness of other people's minds that typical people start developing at a relatively young age, that is, the autistic person doesn't so readily develop theories about what is going on in other people's minds. A corollary is that an autistic person's awareness of other people's minds is something that is developed intellectually through their own efforts.
Furthermore, adherents of this theory suppose that some or all the other typical characteristics of autism stem from this one main deficit. The hypothesis is explained in some books (some have "Theory of Mind" in the title, also Uta Frith has written on it and simple tests have been devised to test a person's awareness of other minds.

These are the frequently asked questions by members of the public with regards to autism and I will try to address some if not all of the questions.

What is Autism?
Autism is a life-long developmental disability that prevents individuals from properly understanding what they see, hear, and otherwise sense. This results in severe problems of social relationships, communication, and behaviour.

Individuals with autism have to painstakingly learn normal patterns of speech and communication, and appropriate ways to relate to people, objects, and events, in a similar manner to those who have had a stroke.

What are the characteristics of autism?
The degree of severity of characteristics differs from person to person, but usually includes the following:
Severe delays in language development
Language is slow to develop, if it develops at all. If it does develop, it usually includes peculiar speech patterns or the use of words without attachment to their normal meaning. Those who are able to use language effectively may still use unusual metaphors or speak in a formal and monotone voice.
Severe delays in understanding social relationships
The autistic child often avoids eye contact, resists being picked up, and seems to "tune out" the world around him. This results in a lack of cooperative play with peers, an impaired ability to develop friendships, and an inability to understand other people's feelings.
Inconsistent Patterns of sensory responses
The child who has autism at times may appear to be deaf and fail to respond to words or other sounds. At other times, the same child may be extremely distressed by an everyday noise such as a vacuum cleaner or a dog's barking. The child also may show an apparent insensitivity to pain and a lack of responsiveness to cold or heat, or may over-react to any of these.
Uneven patterns of intellectual functioning
The individual may have peak skills - scattered things done quite well in relation to overall functioning - such as drawing, music, computations in math, or memorisation of facts with no regard to importance or lack of it.
On the other hand, the majority of autistic persons have varying degrees of mental retardation, with only 20 per cent having average or above-average intelligence. This combination of intellectual variations makes autism especially perplexing.
Marked restriction of activity and interests
A person who has autism may perform repetitive body movements, such as hand flicking, twisting, spinning, or rocking. This individual may also display repetition by following the same route, the same order of dressing, or the same schedule every day. If changes occur in these routines, the preoccupied child or adult usually becomes very distressed.
Autistic children display unusual behaviour. A typical autistic child's behaviour is likely to include: no speech; non-speech vocalisations; delayed development of speech echolalia; delayed echolalia: repeating something heard at an earlier time; confusion between the pronouns "I" and "You"; lack of interaction with other children; lack of eye contact; lack of response to people; treating other people as if they were inanimate objects; when picked up, offering no "help" ("feels like lifting a sack of potatoes"); preoccupation with hands; flapping hands; spinning; balancing, such as standing on a fence; walking on tiptoes; extreme dislike of certain sounds; extreme dislike of touching certain textures; dislike of being touched; either extremely passive behaviour or extremely nervous, active behaviour; extreme dislike of certain foods; behaviour that is aggressive to others; lack of interest in toys; desire to follow set patterns of behaviour/interaction; desire to keep objects in a certain physical pattern; repetitive behaviour (perseveration); self-injurious behaviour; and "Islets of competence", areas where the child has normal or even advanced competence, such as drawing, music, arithmetic and memory.

There are other conditions which sometimes coincide with autism: synesthesia (an unexpected sensation arises when a particular sense modality is stimulated); and cerebellar abnormalities revealed by MRI scans raised levels of serotonin in the brain

What causes autism?
Autism is a brain disorder, present from birth, which affects the way the brain uses information. The cause of autism is still unknown. Some research suggests a physical problem affecting those parts of the brain that process language and information coming in from the senses. There may be some imbalance of certain chemicals in the brain. Genetic factors may sometimes be involved. Autism may indeed result from a combination of several "causes". No factors in the psychological environment of the child cause autism.

How common is autism?
Autism is one of the four major developmental disabilities. It occurs in one to two of every 1,000 births.

Who is affected with autism?
Autism is distributed throughout the world among all races, nationalities, and social classes. Four of every five people with autism are male.

What is the most common problem in autism?
Individuals with autism have extreme difficulty in learning language and social skills and in relating to people.

How does autism affect behaviour?
In addition to severe language and socialisation problems, people with autism often experience extreme hyperactivity or unusual passivity in relating to parents, family members, and other people.

How severe are behavioural problems in people with autism?
In autism, behavioural problems range from very severe to mild. Severe behavioural problems take the form of highly unusual, aggressive, and in some cases, even self-injurious behaviour. These behaviours may persist and be difficult to change.
In its milder form, autism resembles a learning disability. Usually, however, even people who are only mildly affected are substantially handicapped due to deficits in the areas of communication and socialisation.
Does autism occur in conjunction with other disabilities?
Autism can occur by itself or in association with other developmental disorders such as mental retardation, learning disabilities, and epilepsy.
Autism is best considered as a disability on a continuum from mild to severe. The number of handicaps and degree of mental retardation will determine the location on that continuum.
What is the difference between autism and mental retardation?
Most people with mental retardation show relatively even skill development, while individuals with autism typically show uneven skill development with deficits in certain areas - most frequently in their ability to communicate and relate to others - and distinct skills in other areas.
It is important to distinguish autism from mental retardation or other disorders since diagnostic confusion may result in referral to inappropriate and ineffective treatment techniques.

Can people with autism be helped?
Yes, autism is treatable. Studies show that all people who have autism can improve significantly with proper instruction. Many individuals with autism eventually become more responsive to others as they learn to understand the world around them.

How can persons with autism learn best?
Through specially trained teachers, using specially structured programmes that emphasise individual instruction, persons with autism can learn to function at home and in the community. Some can lead nearly normal lives.

What kinds of jobs can individuals with autism do?
In general, individuals with autism perform best at jobs which are structured and involve a degree of repetition. Some people who have autism are working as artists, piano tuners, painters, farm workers, office workers, computer operators, dishwashers, assembly line workers, or competent employees of sheltered workshops or other sheltered work settings.

What leisure activities do persons with autism enjoy?
Individuals who have autism often enjoy the same recreational activities as their non-handicapped peers. They usually like music, swimming, hiking, camping, working puzzles, and playing table games.

What services are available for people with autism in Brunei Darussalam?
The Child Development Centre (CDC) of Ministry of Health, The Special Education Unit of Ministry of Education as well as Pusat Bahagia of Ministry of Culture, Youth and Sports, there are also organisation such as KACA and Pusat Ehsan.
There are school classrooms, social skills training, job training, and life planning services for persons with autism in Brunei Darussalam for persons with autism provided by SMARTER Brunei.

What additional services are needed for children with autism in Brunei Darussalam?
Children with autism need: respite care; before- and after-school care; recreational programmes; and prevocational training.
What do people with autism need when they become adults?
Adults with autism need: vocational training; job opportunities; and recreational opportunities.

How can people who have autism learn meaningful job skills?
With the help of specially trained job coaches, people with autism can learn skills that will enable them to successfully work in competitive employment, supported employment, or in sheltered workshop programmes.

In what ways can persons with autism have relative independence in living?
They can learn skills to live as independently as possible through specifically designed programmes in appropriate centres and supervised home programmes.

What groups in Brunei Darussalam working to help people with autism?
Besides the CDC of Ministry of Health, the Special Education Unit of Ministry of Education as well as Pusat Bahagia of Ministry of Culture, Youth and Sports, there are also organisation such as KACA and Pusat Ehsan, while SMARTER Brunei, which is a family support group comprising parents, professionals, students, and others, focusses only on dealing with autism spectrum disorder and its existence is to raising the visibility of autism and broadening services for individuals who have autism.
The organisation furnishes support to parents, siblings, and professionals in the form of information and referral, autism spectrum disorder centre for early intervention programme, intermediatery intervention programme and also high functioning intervention centre, job coach services, public education, advocacy for adult centre and life planning services, and news and information to everyone.

Source: Weekend 4 April 2009