Muhammad Wajeeh Anis, Mina Mansoor, Mohammad Ijlal Younus
Madam, Betamethasone is a potent steroid medication with immunosuppressive and anti-inflammatory properties, and it is frequently prescribed in Pakistan for conditions such as eczema, psoriasis and contact dermatitis due to its availability and affordability. However, it has significant adverse effects such as skin atrophy, striae and other cutaneous symptoms, and glaucoma.[1] Glaucoma is a severe condition characterized by pathologic elevation in intraocular pressure, leading to optic nerve damage and irreversible blindness. As highlighted by Sahni et al. topical steroid use in the periorbital area for an extended peri, for treating eczema can lead to detrimental visual problems and glaucoma [2]. In this case, a woman taking high dose topical steroids since the age of 16 started to develop frequent falls and blurring of vision. She had markedly elevated intraocular pressures and extensive peripheral visual field loss, consistent with advanced glaucoma. In addition to the study above Charles et al. also published a case report about a 43-year-old male who used betamethasone ointment on his body for eight months straight. Although he had precisely denied using the ointment near his eyes, he developed painless vision loss in his left eye due to glaucoma.[3] Additionally, a 2017 study highlighted a significant rise of vision impairment in Pakistan, an increase of 55% since 1990, with glaucoma prevalent in 0.14 million individuals, and eye diseases to further increase by 2025.[4] Consequently, this medication, which is being discontinued around the world, is still frequently used in Pakistan. Through this manuscript, I would like to bring this serious issue to light so that people in Pakistan can also be educated and protected from this serious side effect. Healthcare practitioners should strictly be avoiding this medication and using less harmful alternatives.
{"title":"Betamethasone and vision loss: An alarming side effect!","authors":"Muhammad Wajeeh Anis, Mina Mansoor, Mohammad Ijlal Younus","doi":"10.47391/jpma.9815","DOIUrl":"https://doi.org/10.47391/jpma.9815","url":null,"abstract":"Madam, Betamethasone is a potent steroid medication with immunosuppressive and anti-inflammatory properties, and it is frequently prescribed in Pakistan for conditions such as eczema, psoriasis and contact dermatitis due to its availability and affordability. However, it has significant adverse effects such as skin atrophy, striae and other cutaneous symptoms, and glaucoma.[1] Glaucoma is a severe condition characterized by pathologic elevation in intraocular pressure, leading to optic nerve damage and irreversible blindness. As highlighted by Sahni et al. topical steroid use in the periorbital area for an extended peri, for treating eczema can lead to detrimental visual problems and glaucoma [2]. In this case, a woman taking high dose topical steroids since the age of 16 started to develop frequent falls and blurring of vision. She had markedly elevated intraocular pressures and extensive peripheral visual field loss, consistent with advanced glaucoma. In addition to the study above Charles et al. also published a case report about a 43-year-old male who used betamethasone ointment on his body for eight months straight. Although he had precisely denied using the ointment near his eyes, he developed painless vision loss in his left eye due to glaucoma.[3] Additionally, a 2017 study highlighted a significant rise of vision impairment in Pakistan, an increase of 55% since 1990, with glaucoma prevalent in 0.14 million individuals, and eye diseases to further increase by 2025.[4] Consequently, this medication, which is being discontinued around the world, is still frequently used in Pakistan. Through this manuscript, I would like to bring this serious issue to light so that people in Pakistan can also be educated and protected from this serious side effect. Healthcare practitioners should strictly be avoiding this medication and using less harmful alternatives.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
None Umm E Salma Banatwala, None Rayaan Imran, None Muhammad Usman Taufiq
Dear Madam, According to the International Diabetes Federation, Pakistan has the highest diabetes prevalence in the world (1).Ttype 1 diabetes (T1DM), a chronic condition where the pancreas makes little or no insulin. Despite extensive research, cure for T1DM has not been found. Typical treatment uses insulin injections, diet modifications, and exercise to manage blood sugar. This letter concisely explains the latest treatments for T1DM. Conventionally, exogenic insulin substitution was done by testing blood sugar levels after finger pricking. However, modern treatments include automated glucose monitoring technology and insulin pumps. Since T1DM is an autoimmune disease caused by the destruction of B-cells, the replacement of B-cells using allogeneic solid organ pancreas or islet transplantation treats the disease (2). However, this treatment requires lifelong immunosuppression drugs, that could lead to severe infections or nephrotoxicity. Other approaches include targeting T-cells, B-cells, or specific single antigens of which limitations range from side effects due to cytokine storm or inability to identify the key antigen. Even though immunotherapies further refined targeted inflammatory pathways, there is a lack of evidence as to if they can restore immune tolerance. On the other hand, therapies targeting cell-intrinsic metabolism may enhance B-cell survival but may result in B-cell dysfunction (2). Given the grim situation of current T1DM treatments, the artificial pancreas is revolutionary. Specific hybrid artificial pancreas required the patient to count the carbohydrates consumed at mealtime. The modern system uses continuous glucose monitoring technology (a sensor inserted under the skin), delivering insulin via the infusion pump according to the blood glucose level. The modern MiniMed 780G artificial pancreas is the first insulin delivery system to automatically administer bolus correction insulin dosage every 5 minutes and adjust insulin doses based on glucose levels. This technology can rectify insufficient or skipped pre-meal dosages by providing extra insulin. A study of 4120 780G users reported that outcomes matched the recommended goals by the American Diabetes Association’s Standards while commending its ability to achieve low variability in glycemic controls (3). Another prospective study published in 2023 concluded that switching to the 780G improves the restoration of hypoglycemia awareness and metabolic control(4). One notable side effect of this system is localized skin infection(5). In conclusion, treatment options for T1DM are ever-growing. The artificial pancreas shows promising results with milder side effects compared to other treatments. Further advancements are integral.
{"title":"Newest and most promising Type 1 Diabetes treatment","authors":"None Umm E Salma Banatwala, None Rayaan Imran, None Muhammad Usman Taufiq","doi":"10.47391/jpma.9916","DOIUrl":"https://doi.org/10.47391/jpma.9916","url":null,"abstract":"Dear Madam, According to the International Diabetes Federation, Pakistan has the highest diabetes prevalence in the world (1).Ttype 1 diabetes (T1DM), a chronic condition where the pancreas makes little or no insulin. Despite extensive research, cure for T1DM has not been found. Typical treatment uses insulin injections, diet modifications, and exercise to manage blood sugar. This letter concisely explains the latest treatments for T1DM. Conventionally, exogenic insulin substitution was done by testing blood sugar levels after finger pricking. However, modern treatments include automated glucose monitoring technology and insulin pumps. Since T1DM is an autoimmune disease caused by the destruction of B-cells, the replacement of B-cells using allogeneic solid organ pancreas or islet transplantation treats the disease (2). However, this treatment requires lifelong immunosuppression drugs, that could lead to severe infections or nephrotoxicity. Other approaches include targeting T-cells, B-cells, or specific single antigens of which limitations range from side effects due to cytokine storm or inability to identify the key antigen. Even though immunotherapies further refined targeted inflammatory pathways, there is a lack of evidence as to if they can restore immune tolerance. On the other hand, therapies targeting cell-intrinsic metabolism may enhance B-cell survival but may result in B-cell dysfunction (2). Given the grim situation of current T1DM treatments, the artificial pancreas is revolutionary. Specific hybrid artificial pancreas required the patient to count the carbohydrates consumed at mealtime. The modern system uses continuous glucose monitoring technology (a sensor inserted under the skin), delivering insulin via the infusion pump according to the blood glucose level. The modern MiniMed 780G artificial pancreas is the first insulin delivery system to automatically administer bolus correction insulin dosage every 5 minutes and adjust insulin doses based on glucose levels. This technology can rectify insufficient or skipped pre-meal dosages by providing extra insulin. A study of 4120 780G users reported that outcomes matched the recommended goals by the American Diabetes Association’s Standards while commending its ability to achieve low variability in glycemic controls (3). Another prospective study published in 2023 concluded that switching to the 780G improves the restoration of hypoglycemia awareness and metabolic control(4). One notable side effect of this system is localized skin infection(5). In conclusion, treatment options for T1DM are ever-growing. The artificial pancreas shows promising results with milder side effects compared to other treatments. Further advancements are integral.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105066","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Madam, 17-Hydroxyprogesterone caproate is a synthetic progestin medication used to prevent preterm birth in pregnant women with a prior history of preterm birth. The drug has been used worldwide, including in Pakistan (local brand names Gravibinan and Proluton) for the prevention of PTBs and recurrent miscarriages. The drug is potent, cost-effective and readily available as IM injections. The FDA approved drug in 2011 after the Meis trial, which was regarded as a game-changer. [1] But many subsequent trials showed that the drug did not significantly lowered the risks of preterm births. The PROLONG study, much larger than the Meis trial, that was conducted in association with the FDA between 2009 and 2018 as a confirmatory trial showed practice-changing results that 17 OHPC did not significantly reduce the risk of PTB and neonatal morbidity, hence not confirming treatment efficacy. [2] The FDA ultimately in 2023 issued a statement recalling Makena (17-OHPC) and its generics from the market stating that the drug had no significant role in reducing the risk of PTBs and has potential risks to the offspring in the long term. [3] A study by C. Murphy et. al published in the American Journal of Obstetrics and Gynecology showed an increased risk of prostate, colorectal and pediatric brain cancer in offspring exposed to 17 OHPC especially during the first trimester. [4] Micronized progesterones (locally available as Progefik and U-Progest) on the contrary, are chemically similar to human progesterone and are therefore regarded as ‘body-identical’. They are administered orally or vaginally and have similar effects as 17-OHPC in the prevention of PTB. A comparative study in India by Shambhavi et.al was one of the various studies to show that no significant difference in the two medications for the prevention of PTB and neonatal morbidity. [5] Micronized progesterone has largely gained popularity in recent years and has replaced 17-OHPC in preventing PTBs especially in women with short cervix. 17-OHPC is still being widely prescribed in Pakistan. Efforts should be made to spread awareness among the healthcare practitioners regarding the disapproval by FDA for continued use of 17-OHPC. Pakistan’s Drug Regulation Authority needs to act accordingly regarding the continued approval of the drug in the country and spread awareness about its substitutes with better potency and reduced risks. Moreover, continued research about the efficacy of other progesterones administered to reduce PTBs and their potential risk factors in the long run is needed.
{"title":"Discontinuation of long-established Hydroxyprogesterone Caproate; call for awareness and drug-substitutes: A Letter to the Editor","authors":"None Muhammad Affan, None Erum Ilyas","doi":"10.47391/jpma.9960","DOIUrl":"https://doi.org/10.47391/jpma.9960","url":null,"abstract":"Madam, 17-Hydroxyprogesterone caproate is a synthetic progestin medication used to prevent preterm birth in pregnant women with a prior history of preterm birth. The drug has been used worldwide, including in Pakistan (local brand names Gravibinan and Proluton) for the prevention of PTBs and recurrent miscarriages. The drug is potent, cost-effective and readily available as IM injections. The FDA approved drug in 2011 after the Meis trial, which was regarded as a game-changer. [1] But many subsequent trials showed that the drug did not significantly lowered the risks of preterm births. The PROLONG study, much larger than the Meis trial, that was conducted in association with the FDA between 2009 and 2018 as a confirmatory trial showed practice-changing results that 17 OHPC did not significantly reduce the risk of PTB and neonatal morbidity, hence not confirming treatment efficacy. [2] The FDA ultimately in 2023 issued a statement recalling Makena (17-OHPC) and its generics from the market stating that the drug had no significant role in reducing the risk of PTBs and has potential risks to the offspring in the long term. [3] A study by C. Murphy et. al published in the American Journal of Obstetrics and Gynecology showed an increased risk of prostate, colorectal and pediatric brain cancer in offspring exposed to 17 OHPC especially during the first trimester. [4] Micronized progesterones (locally available as Progefik and U-Progest) on the contrary, are chemically similar to human progesterone and are therefore regarded as ‘body-identical’. They are administered orally or vaginally and have similar effects as 17-OHPC in the prevention of PTB. A comparative study in India by Shambhavi et.al was one of the various studies to show that no significant difference in the two medications for the prevention of PTB and neonatal morbidity. [5] Micronized progesterone has largely gained popularity in recent years and has replaced 17-OHPC in preventing PTBs especially in women with short cervix. 17-OHPC is still being widely prescribed in Pakistan. Efforts should be made to spread awareness among the healthcare practitioners regarding the disapproval by FDA for continued use of 17-OHPC. Pakistan’s Drug Regulation Authority needs to act accordingly regarding the continued approval of the drug in the country and spread awareness about its substitutes with better potency and reduced risks. Moreover, continued research about the efficacy of other progesterones administered to reduce PTBs and their potential risk factors in the long run is needed.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"32 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Namirah Iftikhar, None Muhammad Osama Rehman Khalid, None Uzma Ghori
Ogilvie's syndrome is a rare but potentially life-threatening condition characterised by massive dilation of the colon without a mechanical obstruction. It typically affects older adults and those with underlying medical conditions, such as neurological or cardiovascular diseases, and may result in severe complications such as perforation or sepsis. Diagnosis is based on clinical presentation and radiological studies, and treatment involves a combination of conservative measures, such as bowel rest and pharmacological agents, and interventional procedures, such as endoscopic decompression or surgery. Here we present the case of a 67 year old male who presented with Ogilvie’s syndrome after changes in his antipsychotic medications. He was given laxatives which led to persistent hypokalemia contributing to worsening distention. This case report highlights the important aspects in management such as cautious use of secretory laxatives (causing worsening Hypokalemia) and combination of motility agents in pseudo colonic obstruction.
{"title":"Ogilvie syndrome secondary due to underlying hypokalaemia and anticholinergics: case report and brief review of the literature","authors":"Namirah Iftikhar, None Muhammad Osama Rehman Khalid, None Uzma Ghori","doi":"10.47391/jpma.8661","DOIUrl":"https://doi.org/10.47391/jpma.8661","url":null,"abstract":"Ogilvie's syndrome is a rare but potentially life-threatening condition characterised by massive dilation of the colon without a mechanical obstruction. It typically affects older adults and those with underlying medical conditions, such as neurological or cardiovascular diseases, and may result in severe complications such as perforation or sepsis. Diagnosis is based on clinical presentation and radiological studies, and treatment involves a combination of conservative measures, such as bowel rest and pharmacological agents, and interventional procedures, such as endoscopic decompression or surgery. Here we present the case of a 67 year old male who presented with Ogilvie’s syndrome after changes in his antipsychotic medications. He was given laxatives which led to persistent hypokalemia contributing to worsening distention. This case report highlights the important aspects in management such as cautious use of secretory laxatives (causing worsening Hypokalemia) and combination of motility agents in pseudo colonic obstruction.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"56 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105878","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Objective: To assess the elasticity of placenta using shear wave elastography in normal and high-risk pregnancies in the third trimester. Method: The prospective, observational study was conducted at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi, from September 15, 2022, to January 15, 2023, and comprised singleton pregnant women during 28-40 weeks of gestation who were referred from the obstetric department. The subjects were divided into normal pregnancy group A and high-risk pregnancy group B. Risk factors include gestational hypertension, gestational diabetes, intrauterine growth restriction, placenta previa, morbidly adherent placenta, old primigravida, teen age and morbid obesity were noted. All the patients underwent grey scale, Doppler ultrasonography and shear wave elastography. Data was analysed using SPSS 26. Results: Of the 104 subjects, 78(75%) were in group A and 26(25%) were in group B. The overall mean age was 34.2±3.59 years. In group B, mean placental shear wave velocity was 2.34±1.17m/sec and elasticity was 24.41±25.51kPa compared to 1.42±0.55 m/sec and 13.6±10.23kPa in group A (p<0.05). Significant positive correlation was found between shear wave velocity and elasticity values in both groups (p<0.001). Conclusion: Shear wave elastography was found to be a useful technique in detecting placental stiffness, and can be used as an adjunct to the currently available ultrasonographic methods in high-risk pregnancies. Key Words: Shear wave, Elastography, Placenta, Velocity, Elastic modulus, High-risk pregnancy.
{"title":"Role of shear wave elastography in assessment of placental elasticity in normal and high-risk pregnancies in third trimester","authors":"Sheeza Imtiaz, Nasreen Naz, Ayesha Walid, Anila Rahim, Hira Fatima Waseem","doi":"10.47391/jpma.9314","DOIUrl":"https://doi.org/10.47391/jpma.9314","url":null,"abstract":"Objective: To assess the elasticity of placenta using shear wave elastography in normal and high-risk pregnancies in the third trimester. Method: The prospective, observational study was conducted at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi, from September 15, 2022, to January 15, 2023, and comprised singleton pregnant women during 28-40 weeks of gestation who were referred from the obstetric department. The subjects were divided into normal pregnancy group A and high-risk pregnancy group B. Risk factors include gestational hypertension, gestational diabetes, intrauterine growth restriction, placenta previa, morbidly adherent placenta, old primigravida, teen age and morbid obesity were noted. All the patients underwent grey scale, Doppler ultrasonography and shear wave elastography. Data was analysed using SPSS 26. Results: Of the 104 subjects, 78(75%) were in group A and 26(25%) were in group B. The overall mean age was 34.2±3.59 years. In group B, mean placental shear wave velocity was 2.34±1.17m/sec and elasticity was 24.41±25.51kPa compared to 1.42±0.55 m/sec and 13.6±10.23kPa in group A (p<0.05). Significant positive correlation was found between shear wave velocity and elasticity values in both groups (p<0.001). Conclusion: Shear wave elastography was found to be a useful technique in detecting placental stiffness, and can be used as an adjunct to the currently available ultrasonographic methods in high-risk pregnancies. Key Words: Shear wave, Elastography, Placenta, Velocity, Elastic modulus, High-risk pregnancy.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"22 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136106041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dear Madam, With an estimated 6.5 million people living with dementia in the South Asian region, these areas are at the forefront of tackling the growing epidemic. However, there is a scarcity of population-based studies particularly in lower-middle-income countries, which hampers accurate estimation of the economic burden posed by dementia (1). Pakistan, with the world’s third largest growing population is a model of these countries. Although the Global Action Plan for Public Health Response to Dementia highlights seven action areas, the Global Dementia Observatory (GDO) report has Pakistan underperforming in almost all areas. In comparison, her neighbors, India, China and Iran are significantly better. With no health information systems for dementia, and no support or care for people with dementia, Pakistan has failed to consider dementia as a public health priority (1). Reports show that Pakistan is drafting a national policy for dementia, yet no surveys on national prevalence and cost have been conducted (2). Apart from an ageing population, low literacy levels and high prevalence of heart diseases and diabetes, make the population highly susceptible to developing AD in the coming future. Furthermore, a challenge especially to LMICs is the stigma associated with dementia and the lack of awareness, not just in the general population, but also in the healthcare providers. Alzheimer’s Disease International reports that almost 2 in 3 healthcare practitioners worldwide consider dementia as part of normal ageing (3). Only if these beliefs are reformed can the disease be tackled efficiently. For a nation with no infrastructure to support patients with AD and where MRI is unaffordable to the majority and scarcely available PET scans are not used for the diagnosis of AD, the population would rely on the establishment of fluid biomarkers not only for diagnosing AD, but for its identification at a stage where it is possible to reduce the years lost to dependence. Unfortunately, our search on PubMed and Google Scholar revealed only one AD biomarker study conducted by the current authors on our population (4). Recently a constructive step was taken by lay and professional experts where a SWOT analysis was done of dementia research capacity in Pakistan. ---Continue
{"title":"The road to crisis: State of Pakistan’s Research Output in Dementia","authors":"Tehniat Faraz Ahmed, Affan Ahmed","doi":"10.47391/jpma.9548","DOIUrl":"https://doi.org/10.47391/jpma.9548","url":null,"abstract":"Dear Madam, With an estimated 6.5 million people living with dementia in the South Asian region, these areas are at the forefront of tackling the growing epidemic. However, there is a scarcity of population-based studies particularly in lower-middle-income countries, which hampers accurate estimation of the economic burden posed by dementia (1). Pakistan, with the world’s third largest growing population is a model of these countries. Although the Global Action Plan for Public Health Response to Dementia highlights seven action areas, the Global Dementia Observatory (GDO) report has Pakistan underperforming in almost all areas. In comparison, her neighbors, India, China and Iran are significantly better. With no health information systems for dementia, and no support or care for people with dementia, Pakistan has failed to consider dementia as a public health priority (1). Reports show that Pakistan is drafting a national policy for dementia, yet no surveys on national prevalence and cost have been conducted (2). Apart from an ageing population, low literacy levels and high prevalence of heart diseases and diabetes, make the population highly susceptible to developing AD in the coming future. Furthermore, a challenge especially to LMICs is the stigma associated with dementia and the lack of awareness, not just in the general population, but also in the healthcare providers. Alzheimer’s Disease International reports that almost 2 in 3 healthcare practitioners worldwide consider dementia as part of normal ageing (3). Only if these beliefs are reformed can the disease be tackled efficiently. For a nation with no infrastructure to support patients with AD and where MRI is unaffordable to the majority and scarcely available PET scans are not used for the diagnosis of AD, the population would rely on the establishment of fluid biomarkers not only for diagnosing AD, but for its identification at a stage where it is possible to reduce the years lost to dependence. Unfortunately, our search on PubMed and Google Scholar revealed only one AD biomarker study conducted by the current authors on our population (4). Recently a constructive step was taken by lay and professional experts where a SWOT analysis was done of dementia research capacity in Pakistan. ---Continue","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105379","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Madam, Traumatic brain injury (TBI) refers to non-congenital, non-degenerative damage to the brain caused by an external mechanical force which can lead to permanent or temporary impairment of cognitive, psychosocial, and physical functions, accompanied by a reduced or altered state of consciousness.1 TBI is the most frequently occurring among common neurological disorders and accounts for a significant public health challenge.2 TBI has a high prevalence worldwide in adolescent (15 to 18 years) and elderly (>65 years) groups with a reported incidence of 1.7 million cases in the US alone.3 Pakistan also has a high prevalence of TBI with approximately one-third of its population being affected by it mainly due to the high incidence of road traffic accidents.4 Patients with TBI often present with clinical features of shock especially when the mechanism of injury is associated with high-energy trauma like road traffic accidents. In such cases, there is an imminent need for fluid resuscitation which becomes more important in under-served areas where immediate neurosurgical care is not available. It is widely known that crystalloids are superior to colloids for the resuscitation of the patient in such settings.5 The ringer lactate solution is usually preferred over normal saline for resuscitation in non-TBI settings because of lower mortality but the same is not true in TBI settings in which normal saline has been reported with significantly lower mortality. This difference can be attributed to the fact that ringer lactate being a balanced crystalloid, is hypo-osmotic, and thus can increase the intracranial pressure as well as the incidence of hyponatremia in patients with TBI.6 Therefore, in TBI, normal saline should be the fluid of choice for resuscitation instead of ringer lactate solution. The choice of fluid for resuscitation is of paramount importance in TBI, especially in a country like Pakistan where advanced healthcare facilities for neurosurgical care are not available in every city and village. Hence, many patients get referred to tertiary care centers from primary and secondary care centers after initial resuscitation for further management. In such cases, the correct choice of resuscitation fluid can significantly help in improving the odds of survival till patient’s arrival at higher care facility, and thereby help in decreasing the overall mortality associated with TBI.
{"title":"Can the choice of resuscitation fluid in a patient with traumatic brain injury affect the outcome?","authors":"Umar Nadeem, Sobia Sarwar, None Bilal Ahmad","doi":"10.47391/jpma.10032","DOIUrl":"https://doi.org/10.47391/jpma.10032","url":null,"abstract":"Madam, Traumatic brain injury (TBI) refers to non-congenital, non-degenerative damage to the brain caused by an external mechanical force which can lead to permanent or temporary impairment of cognitive, psychosocial, and physical functions, accompanied by a reduced or altered state of consciousness.1 TBI is the most frequently occurring among common neurological disorders and accounts for a significant public health challenge.2 TBI has a high prevalence worldwide in adolescent (15 to 18 years) and elderly (>65 years) groups with a reported incidence of 1.7 million cases in the US alone.3 Pakistan also has a high prevalence of TBI with approximately one-third of its population being affected by it mainly due to the high incidence of road traffic accidents.4 Patients with TBI often present with clinical features of shock especially when the mechanism of injury is associated with high-energy trauma like road traffic accidents. In such cases, there is an imminent need for fluid resuscitation which becomes more important in under-served areas where immediate neurosurgical care is not available. It is widely known that crystalloids are superior to colloids for the resuscitation of the patient in such settings.5 The ringer lactate solution is usually preferred over normal saline for resuscitation in non-TBI settings because of lower mortality but the same is not true in TBI settings in which normal saline has been reported with significantly lower mortality. This difference can be attributed to the fact that ringer lactate being a balanced crystalloid, is hypo-osmotic, and thus can increase the intracranial pressure as well as the incidence of hyponatremia in patients with TBI.6 Therefore, in TBI, normal saline should be the fluid of choice for resuscitation instead of ringer lactate solution. The choice of fluid for resuscitation is of paramount importance in TBI, especially in a country like Pakistan where advanced healthcare facilities for neurosurgical care are not available in every city and village. Hence, many patients get referred to tertiary care centers from primary and secondary care centers after initial resuscitation for further management. In such cases, the correct choice of resuscitation fluid can significantly help in improving the odds of survival till patient’s arrival at higher care facility, and thereby help in decreasing the overall mortality associated with TBI.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"7 4","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dear Madam, An ever-worsening economic crisis, has hit Pakistan, and the political crisis and recent floods have added to the worsening situation [1]. The inflation rate in Pakistan has hit a record high of 35.4%, leading to the manufacturers’ increase in the cost of essentials and amenities [2]. However, pharmaceuticals have still not been allowed to increase their products’ prices, making it difficult for them to thrive, which has led to their decrease in number over the last few years [3]. Since 2018, the number of foreign pharmaceutical companies in Pakistan has been reduced from 48 to 22. [4]. The local sector is in no better position. Pakistan's pharmaceutical industry has warned that local businesses will have to cease due to extortionate production costs and the devaluation of the rupee, difficulties with imports, and rising inflation [5]. As many as 770 drug manufacturers in Pakistan have been impacted by the medicine shortage crisis consequent to a lack of essential raw products and materials imports [6]. More companies are expected to stop producing medicines owing to high costs in the upcoming days, which may lead to the number of scarce drugs in the country increasing from 500 to 2,500 [7]. Pakistan is the only country with a regulatory authority that controls the prices of all medicines. [8]. This entire situation has created an immense burden for consumers, who are compelled to face the consequence of medicine shortage, forcing them to buy medicines at a much higher cost. The deficit has also led to the production of counterfeit drugs, hurting not only the existing industries but also putting patients’ lives at very high risk. The industry's greatest worry is the complete freezing of pharmaceutical product prices. The government-set pricing structure prevents the pharmaceutical industry from raising the price of any drugs, even those whose costs have increased by more than 100%. With significantly increasing input, associated costs like fuel, electricity, labour, and raw materials have made it difficult for the industry to survive [8]. The government should pay immediate attention to this problem. The Drug Regulatory Authority of Pakistan (DRAP) needs to implement new policies allowing pharmaceutical to increase their products’ prices, ensuring not to overburden consumers with it. DRAP should be strengthened by upgrading to maintain global standards. ---Continue
{"title":"The Dilemma of Pharmaceutical Companies in Pakistan: Navigating Price Regulations During a Time of High Inflation","authors":"Noman Mansoor, Aimen Warsi","doi":"10.47391/jpma.9790","DOIUrl":"https://doi.org/10.47391/jpma.9790","url":null,"abstract":"Dear Madam, An ever-worsening economic crisis, has hit Pakistan, and the political crisis and recent floods have added to the worsening situation [1]. The inflation rate in Pakistan has hit a record high of 35.4%, leading to the manufacturers’ increase in the cost of essentials and amenities [2]. However, pharmaceuticals have still not been allowed to increase their products’ prices, making it difficult for them to thrive, which has led to their decrease in number over the last few years [3]. Since 2018, the number of foreign pharmaceutical companies in Pakistan has been reduced from 48 to 22. [4]. The local sector is in no better position. Pakistan's pharmaceutical industry has warned that local businesses will have to cease due to extortionate production costs and the devaluation of the rupee, difficulties with imports, and rising inflation [5]. As many as 770 drug manufacturers in Pakistan have been impacted by the medicine shortage crisis consequent to a lack of essential raw products and materials imports [6]. More companies are expected to stop producing medicines owing to high costs in the upcoming days, which may lead to the number of scarce drugs in the country increasing from 500 to 2,500 [7]. Pakistan is the only country with a regulatory authority that controls the prices of all medicines. [8]. This entire situation has created an immense burden for consumers, who are compelled to face the consequence of medicine shortage, forcing them to buy medicines at a much higher cost. The deficit has also led to the production of counterfeit drugs, hurting not only the existing industries but also putting patients’ lives at very high risk. The industry's greatest worry is the complete freezing of pharmaceutical product prices. The government-set pricing structure prevents the pharmaceutical industry from raising the price of any drugs, even those whose costs have increased by more than 100%. With significantly increasing input, associated costs like fuel, electricity, labour, and raw materials have made it difficult for the industry to survive [8]. The government should pay immediate attention to this problem. The Drug Regulatory Authority of Pakistan (DRAP) needs to implement new policies allowing pharmaceutical to increase their products’ prices, ensuring not to overburden consumers with it. DRAP should be strengthened by upgrading to maintain global standards. ---Continue","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105869","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dear Madam, Environmental tobacco smoke (ETS), also referred to as second-hand, involuntary, or passive smoke, is produced from the combustion of tobacco products or puffed out by active smokers. The smoke emitted from the tip of a cigarette contains about two times the concentration of nicotine, five times the concentration of Carbon monoxide, and 50 times the concentration of ammonia than active smoke1. Furthermore, amongst the exposed population, children are far more susceptible to complications associated with ETS due to their manner of exposure and developmental physiology. According to the 2014 Global Adult Tobacco Survey for Pakistan, 43.3% of households were exposed to ETS, with a significant amount of children included in that percentage2. Thus, children's health is more detrimentally impacted by ETS than adults. Exposure of children to ETS in domestic and public settings risks a higher occurrence of respiratory and middle-ear diseases. According to numerous studies, dose-dependent exposure to ETS directs more frequent and severe asthma attacks accompanied by wheezing. Moreover, it is observed that school-aged individuals who live in a smoking household tend to develop a range of lung diseases, including bronchitis, bronchiolitis, and pneumonia. Their lungs become weak, resulting in impaired pulmonary function3. With reference to a population-based cohort study conducted by Lovasi et al. (ref 4), it was evident that childhood ETS exposure from 2 or more smokers compared with none is linked with early emphysema in adulthood4. In addition, constant ETS exposure leads to swelling and obstruction of the eustachian tube, which interferes with pressure equalization leading to pain, fluid accumulation, and infection. Ear infections and middle ear fluid are the most common causes of hearing loss in children. Being the primary reason behind several disease, ETS is also known to cause acute effects on cardiovascular function in children. Compelling evidence demonstrates that childhood ETS exposure risks the accumulation of factors associated with cardiovascular diseases, including obesity, dyslipidemia, and imbalanced systolic and diastolic blood pressure5. [Exposure to hazardous chemicals found in ETS, for instance, benzopyrene, is known to accelerate the development of atherosclerosis]. Moreover, studies show convincing evidence that hypertension is common in children exposed to ETS at home. It is also observed that hypertension is a common risk factor for cardiovascular disease and cardiovascular stress hyperactivity in children with smoking parents. ---Continue
{"title":"Passive smoking and the health of children: a primary concern in Pakistan","authors":"Syeda Fatima Mehdi Jafri, None Syeda Fizza Hussain, None Wajiha Zehra","doi":"10.47391/jpma.9421","DOIUrl":"https://doi.org/10.47391/jpma.9421","url":null,"abstract":"Dear Madam, Environmental tobacco smoke (ETS), also referred to as second-hand, involuntary, or passive smoke, is produced from the combustion of tobacco products or puffed out by active smokers. The smoke emitted from the tip of a cigarette contains about two times the concentration of nicotine, five times the concentration of Carbon monoxide, and 50 times the concentration of ammonia than active smoke1. Furthermore, amongst the exposed population, children are far more susceptible to complications associated with ETS due to their manner of exposure and developmental physiology. According to the 2014 Global Adult Tobacco Survey for Pakistan, 43.3% of households were exposed to ETS, with a significant amount of children included in that percentage2. Thus, children's health is more detrimentally impacted by ETS than adults. Exposure of children to ETS in domestic and public settings risks a higher occurrence of respiratory and middle-ear diseases. According to numerous studies, dose-dependent exposure to ETS directs more frequent and severe asthma attacks accompanied by wheezing. Moreover, it is observed that school-aged individuals who live in a smoking household tend to develop a range of lung diseases, including bronchitis, bronchiolitis, and pneumonia. Their lungs become weak, resulting in impaired pulmonary function3. With reference to a population-based cohort study conducted by Lovasi et al. (ref 4), it was evident that childhood ETS exposure from 2 or more smokers compared with none is linked with early emphysema in adulthood4. In addition, constant ETS exposure leads to swelling and obstruction of the eustachian tube, which interferes with pressure equalization leading to pain, fluid accumulation, and infection. Ear infections and middle ear fluid are the most common causes of hearing loss in children. Being the primary reason behind several disease, ETS is also known to cause acute effects on cardiovascular function in children. Compelling evidence demonstrates that childhood ETS exposure risks the accumulation of factors associated with cardiovascular diseases, including obesity, dyslipidemia, and imbalanced systolic and diastolic blood pressure5. [Exposure to hazardous chemicals found in ETS, for instance, benzopyrene, is known to accelerate the development of atherosclerosis]. Moreover, studies show convincing evidence that hypertension is common in children exposed to ETS at home. It is also observed that hypertension is a common risk factor for cardiovascular disease and cardiovascular stress hyperactivity in children with smoking parents. ---Continue","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"40 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105880","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The study aimed to explore the association between hip flexors tightness and lumbar instability in adults. The study design was correlational and 64 subjects of both genders (male and female) with age range from 20 to 50 years were selected with a history of low back pain (LBP) with or without referred pain. Two examiners were assigned for application of the Modified Thomas Test (MTT) for hip flexors tightness and lumbar prone Instability Test (LPIT) and Prone Lumbar Extension Tests (PLET) for lumbar instabilities. The numeric pain rating scale (NPRS) was used for pain assessment. The two examiners were not aware of each other’s findings. The lambda value 0.238 which shows there is a weak association between MTT and PLET. The Cramer’s V value 0.179 also shows a weak relationship between MTT and LPIT. This study observed that there is a weak association between tight hip flexors and lumbar instability.
{"title":"Association between hip flexor tightness and lumbar instability in adults","authors":"Asghar Khan, Arshad Nawaz Malik","doi":"10.47391/jpma.8221","DOIUrl":"https://doi.org/10.47391/jpma.8221","url":null,"abstract":"The study aimed to explore the association between hip flexors tightness and lumbar instability in adults. The study design was correlational and 64 subjects of both genders (male and female) with age range from 20 to 50 years were selected with a history of low back pain (LBP) with or without referred pain. Two examiners were assigned for application of the Modified Thomas Test (MTT) for hip flexors tightness and lumbar prone Instability Test (LPIT) and Prone Lumbar Extension Tests (PLET) for lumbar instabilities. The numeric pain rating scale (NPRS) was used for pain assessment. The two examiners were not aware of each other’s findings. The lambda value 0.238 which shows there is a weak association between MTT and PLET. The Cramer’s V value 0.179 also shows a weak relationship between MTT and LPIT. This study observed that there is a weak association between tight hip flexors and lumbar instability.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"9 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136104917","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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