Haider Ghazanfar

Ebola, the killer virus

Ebola virus disease (EVD) has mostly affected economically deprived countries as limited resources adversely affect a country’s infrastructure and administration. Probing into the factors that led to the widespread outbreak, setting forth plans to counter EVD cases in developing countries, and devising definitive measures to limit the spread of the disease are essential steps that must be immediately taken. In this review we summarize the pathogenesis of EVD and the factors that led to its spread. We also highlight interventions employed by certain countries that have successfully limited the epidemic, and add a few preventive measures after studying the current data. According to the available data, barriers to prevent and control the disease in affected countries include irresolute and disorganized health systems, substandard sanitary conditions, poor personal hygiene practices, and false beliefs and stigma related to EVD. The public health sector along with the respective chief authorities in developing countries must devise strategies, keeping the available resources in mind, to deal with the outbreak before it occurs. As a first step, communities should be educated on EVD’s symptoms, history, mode of transmission, and methods of protection, including the importance of personal hygiene practices, via seminars, newspapers, and other social media. A popular opinion leader (POL) giving this information would further help to remove the misconception about the nature of the disease and indirectly improve the quality of life of affected patients and their families.

Importance of Mean Red Cell Distribution Width in Hypertensive Patients

Purpose Red cell distribution width (RDW), expressed in femtoliters (fl), is a measure of the variation in the size of circulating erythrocytes and is often expressed as a direct measurement of the width of the distribution. We aim to observe the mean value of red cell distribution width (RDW) in hypertensive patients. Increased RDW can be used as a tool for early diagnosis, as an inflammatory marker, and a mortality indicator in hypertensive patients due to its close relation to inflammation. Materials and methodology Hypertensive patients who had the condition for more than one year duration, diagnosed according to the Joint National Committee (JNC 7) criteria were subjected to complete blood count and RDW measurement. One hundred patients, aged between 12 years and 65 years were enrolled from the outpatient department of medicine at the Military Hospital Rawalpindi. Results The mean age (± SD) of the patients was 51.48 ± 10.08 years. Out of 100 patients 69% were males whereas 31% were females. The overall frequency of hypertension more than five years was 55% subjects whereas 45% individuals had duration of hypertension less than five years. Mean RDW in females was found to be 49.35±8.42 fl while mean RDW in males was 44.78±7.11 fl. An independent sample t-test was applied to assess if there was any significant difference between age and gender. No significant difference between age and gender was found (p<0.05). The Mann-Whitney test was used to assess any association of RDW with gender. RDW values in females was found to be statistically significantly higher than in males (U=603, p=0.01). Linear regression showed that mean RDW value increased with increasing age (P <0.001). Conclusions A significant number of patients with hypertension have increased levels of RDW. Therefore, it is recommended that serum RDW should be checked regularly in patients with hypertension.

Comparison of Serum Magnesium Levels in Overweight and Obese Children and Normal Weight Children

Purpose Abnormalities in serum magnesium levels have been seen in obesity and its related diseases. Our aim is to determine the mean magnesium levels in overweight and obese children as compared to the levels in normal weight controls to study its relationship with obesity and overweight. The study was done at a tertiary care hospital. Methods A case-control study was conducted at the Department of Pediatrics, Combined Military Hospital, Peshawar, over a 12-month period from August 7, 2015 to August 6, 2016. A total of 140 children between 2-14 years of age were included in the study. They were divided into two equal groups of 70 children each. Both of the groups were matched according to their age and sex. Children with a body mass index (BMI) greater than or equal to 85th centile and 95th centile were placed in the overweight and obese category, respectively, and termed as cases while the other 70 children with a BMI greater than or equal to 5th centile but less than 85th centile were categorized as the normal weight group and termed controls. The serum magnesium levels of both case and control groups were calculated. Results The serum magnesium levels were significantly lower in the overweight and obese group (2.08 ± 0.211 mg/dl) as compared to the normal weight group (2.55 ± 0.155 mg/dl, p<0.001). A significantly strong inverse relationship was seen between serum magnesium levels and body mass index. Conclusion Mean serum magnesium levels in overweight and obese children are lower than those in normal weight children. Further studies are required to see the effect of supplementation of diet with this essential micronutrient on the weight of children.

Impact of insulin pump on quality of life of diabetic patients

Aim: Diabetes is an emerging health problem, both in developing and developed countries and has an enormous economic and social impact. The objective of our study was to find the impact of insulin pump on the quality of life of patients with type 2 diabetes (T2D) and compare it to the quality of life of patients with T2D using an insulin pen. Subjects and Methods: This is a case–control study which was conducted among patients with T2D presenting between November 2014 and November 2015. A total of 83 patients with T2D, using insulin pump were enrolled in the study as cases and 322 patients with T2D not using insulin pump but using insulin pens were enrolled as controls. Short form-36 quality of life questionnaire was used for data collection. Results: Mean age of patients using insulin pump was 52.49 ± 9.28 while the mean age of patients not using insulin pump was 54.72 ± 16.87. Mean score of all domains in the questionnaire was found to be higher in patients using insulin pump as compared to patients not using insulin pumps (P < 0.05). In 81.1% of the patients, the insulin pump decreased the frequency of hypoglycemic episodes. Conclusion: Insulin pump has significantly improved the quality of life of patients in terms of better self-esteem, decreased stress, and better mood. It has resulted in improved physical health, meal time flexibility, and ease of travel. It allows patient to have more active participation in social and recreational activities improving their personal and family life.

Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts

Background: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts. Methods: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria. Results: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%. Conclusion: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.

Fatal Fulminant Hepatitis from Rituximab-induced Hepatitis B Reactivation in a Patient with Follicular Lymphoma: A Case Report and a Brief Review of Literature

The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.

Cadaveric Dissection a Thing of the Past? The Insight of Consultants, Fellows, and Residents

Objective The objective of our study was to determine whether cadaveric dissection is a necessity in medical education. Another purpose of our study was to assess the attitude and perception of consultants, residents, and fellows about cadaveric dissection and whether it helped them in their medical practices. Method We performed an analytical cross-sectional study among consultants, fellows, and residents of different specialty areas practicing in Punjab. A self-constructed questionnaire compromising of 41 items was used to assess the perception of doctors about cadaveric dissection and other alternative anatomy teaching methods. Consultants, fellows, and residents who were in clinical practice for more than six months were included in the study. Results Out of the total sample size of 842, 44.7% were female medical doctors and 55.3 % were male medical doctors. Cadaveric dissection was thought to be the most effective method for teaching anatomy by 27.9% of the doctors. Mean cadaveric dissection, prosection and didactic teaching components were scored significantly higher by doctors in surgery and allied fields (p<0.001). Doctors in the surgical and allied field were 0.55 times less likely to think that cadaveric dissection was unethical as compared to doctors working in medicine and allied fields (p<0.001). Conclusion Dissection is still considered by several doctors as a valuable source of learning anatomy. However, the future of teaching anatomy does not depend on any single method. It is, in fact, the right combination of all available resources and using them in an interactive way that maximizes outcomes.

Compassion Satisfaction, Burnout, and Compassion Fatigue in Cardiac Physicians Working in Tertiary Care Cardiac Hospitals in Pakistan

Introduction The purpose of this study is to determine the prevalence and risk factors of compassion satisfaction, compassion fatigue, and burnout among cardiac physicians working in tertiary care cardiac hospitals in Pakistan. Materials and methods We performed a cross-sectional study in four tertiary care cardiac hospitals located in Rawalpindi and Lahore, Pakistan from June 2017 to January 2018. The study comprised of three stages. The first stage involved administration of the Professional Quality of Life Scale (ProQOL-5) questionnaire in order to assess the prevalence of compassion satisfaction, compassion fatigue, and burnout in cardiac physicians. In the second stage, cardiac physicians were divided into two groups according to their compassion fatigue level. In the third stage, 50 participants were selected via convenience sampling to participate in a 15-minute interview regarding compassion fatigue and risk factors. The data obtained was analyzed using the Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM, Armonk, NY). Results The mean age of the participants was found to be 39.2 ± 6.3 years. Out of the 200 participants, 110 (55.0%) were males while 90 (45.0%) were females. The mean score in the compassion satisfaction category was 39.13 ± 5.54 while the mean score of burnout category was 24.7 ± 4.28 and that of secondary traumatic stress (compassion fatigue) was 25.97 ± 6.39. Participants whose age was less than 40 years had a higher score in Burnout (p < 0.001) and secondary traumatic stress category (p < 0.05). Conclusions In Pakistan compassion fatigue, despite being reported as a negative phenomenon, has received little or no attention. There is a dire need to increase awareness about compassion fatigue and burnout among cardiac care physicians in Pakistan.

Oral Health Practices Among Pakistani Physicians

Introduction In most healthcare models, the first interaction of a patient is with a general physician. The inspection of the oral cavity is a mandatory component of the general physical examination performed by a physician. This helps detect any oral pathology and make suitable referrals. Therefore, adequate oral health awareness is essential for physicians. Our study aimed at evaluating the oral health practices among physicians working in a private teaching setup in Islamabad, Pakistan. Methods A cross-sectional study involving 144 physicians teaching undergraduate medical students at Shifa College of Medicine and its affiliated hospital, Shifa International Hospital, was conducted. Participants were interviewed through a self-designed questionnaire. Later, each participant demonstrated their teeth brushing technique on a standard model of the oral cavity, which was assessed against a checklist conforming to the modified bass technique. A video clip showing the aforementioned brushing technique was shown at the end of the interview. The collected data was analyzed on IBMs statistical package for the social sciences (SPSS) version 21. Results Toothpaste was the top choice (97.2%) of teeth cleaning tool with 69% participants brushing their teeth two times a day and 56.9% using toothbrushes with bristles of medium texture. The use of mouthwash (32.6%) and dental floss (11.1%) was considerably low. Dental caries and teeth discoloration were seen in 46.5% and 43.8% physicians, respectively. An alarmingly low number of physicians (31.9%) claimed to have read guidelines regarding oral health. This translated into most participants (78.5%) visiting a dentist only when needed. Only 4.9% participants performed all components of the modified bass technique to clean teeth on the oral cavity model, with up to 22.9% unable to perform a single step accurately. Conclusion The oral health knowledge and practices of physicians were found to be suboptimal and necessitate the integration of oral health awareness in the medical curriculum. A multiprofessional approach with physicians in crucial roles is required to address the burden of dental diseases globally.

Knowledge of Postgraduate Medical Trainees Regarding Epidemiology

Introduction An understanding of epidemiology is fundamental for designing research and understanding evidence-based medicine (EBM). The purpose of our study was to determine the knowledge of epidemiology among postgraduate medical trainees. Methods We carried out a cross-sectional study from January 2017 to June 2017 at the Regional Centre Islamabad, College of Physicians and Surgeons Pakistan. About 204 postgraduate medical trainee were enrolled in the study after taking written consent. All of the participants were working as a postgraduate medical trainee in different hospitals of Rawalpindi and Islamabad. A self-designed structured questionnaire containing 20 multiple choice questions regarding knowledge of epidemiology was given to all the participants. Knowledge of epidemiology was measured and compared with gender, hospital, and previous history of research. Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM, Armonk, NY) was used for data analysis. Results Out of 204 participants, 46.1% participants were males while 53.9% were females. The mean age of the participant was 28.5 ± 2.5. Majority fo the trainees (33.8%) were training in an Internal Medicine residency program. Most of the trainees (76%) had average knowledge of epidemiology while 18.6% of the trainees had good knowledge. Only 17.6% had some experience of research projects in the past, but this was not related to knowledge of epidemiology (p > 0.05). Conclusion Only 18.6% of the postgraduate trainees had good knowledge regarding epidemiology and 76% had average knowledge. This knowledge did not relate to their gender, hospital settings, and previous experience of conducting research proposals and articles.