Kashmira Nanji

Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management

Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. The etiology of fibromyalgia remains unknown, but recent advances and discoveries have helped to unravel some of the mysteries of this disease. Research highlights some of the biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Management of FMS at the present time is very difficult as it has multiple etiological factors and psychological predispositions; however, a patient centered approach is essential to handle this problem.

Effects of polypharmacy on adverse drug reactions among geriatric outpatients at a tertiary care hospital in Karachi: a prospective cohort study.

Background Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, “concurrent use of five or more different prescription medication”. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center. Methods A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University Hospital April 2012 to March 2013. One thousand geriatrics patients (age ≥65 years) visiting ambulatory clinics were identified. They were divided on the basis of exposure (polypharmacy vs. no polypharmacy). We followed them from the time of their enrollment (day zero) to six weeks, checking up on them once a week. Incidence was calculated and Cox Proportional Hazard Model estimates were used. Results The final analysis was performed on 1000 elderly patients. The occurrence of polypharmacy was 70% and the incidence of ADRs was 10.5% among the study cohort. The majority (30%) of patients were unable to read or write. The use of herbal medicine was reported by 3.2% of the patients and homeopathic by 3%. Our Cox adjusted model shows that polypharmacy was 2.3 times more associated with ADRs, con-current complementary and alternative medicine (CAM) was 7.4 times and those who cannot read and write were 1.5 times more associated with ADRs. Conclusion The incidence of ADRs due to poly pharmacy is alarmingly high. The factors associated with ADRs are modifiable. Policies are needed to design and strengthen the prescription pattern.

Patient Attitudes towards Physician Nonverbal Behaviors during Consultancy: Result from a Developing Country

Background. Nonverbal behaviors have a significant impact on patients during consultations. This study was undertaken to find out the attitudes and preferences of the patients regarding nonverbal communication during consultations with physicians, in a tertiary care hospital. Methods. A questionnaire based cross-sectional study was carried out at the Aga Khan University Hospital, Karachi, Pakistan, during the months of January to March 2012. All patients (>18 years of age) coming for consultancy in the family medicine clinics were approached; out of 133, 120 agreed to participate. The subjects were asked questions regarding physicians comforting touch and eye contact and their responses were noted. The data were analyzed using SPSS and chi-square test was used to identify corelations. Results. Overall, 120 patients were enrolled. About 58.3% were men and 41.7% were women with a mean age of 34.9 ± 10.9 years. 95.8% were Muslims and 57.6% had more than 12 years of education. Among females 74% wanted supportive touch from doctors, used to comfort the patient (45%) or to show respect (27.5%) or as healing (30%). 86.1% of the respondents believe that establishing eye contact with the patient shows that the doctor is attentive towards his/her patient. The eye contact should be brief but regular (54.1%) and prolonged staring (36.7%) makes them uncomfortable. Conclusion. Nonverbal communication helps to strengthen the doctor-patient relation as patients do appreciate positive touch and eye contact from their physicians.

A Review on the Role of Vitamin D in Asthma

Asthma, a major public health issue, is one of the most common diseases affecting millions of population globally. It is a chronic respiratory disease characterized by increased airway inflammation and hyper-responsiveness. Vitamin D is of particular interest in asthma due to its immunomodulatory effects. Serum 25-hydroxyvitamin D is found to be associated with a wide range of pulmonary diseases, including viral and bacterial respiratory infections, asthma, and cancer. Several researches have reported positive associations between vitamin D and asthma. On the other hand, others have reported contrasting effects of vitamin D on asthma. This review provides an examination of current epidemiologic and experimental evidence of a causal association between vitamin D status and asthma or asthma exacerbations, including its probable protective mechanism. Most of the evidence regarding vitamin D and asthma is reported by observational studies. Therefore, results from the experimental trials of vitamin D supplementation are important as they can provide evidence for future recommendations about the significance of vitamin D for asthma. Moreover, the trials can be effective in assessing the correct dosage and safety of vitamin D supplementation when given in diverse age groups such as children, teenagers, and adults for prevention and treatment of asthma.

Barriers, challenges and way forward for implementation of person centered care model of patient and physician consultation: a survey of patients’ perspective from Eastern Mediterranean countries

(1) Department of Family Medicine, Aga Khan University, Karachi, Pakistan (2) Director General, Executive Board, Health Ministers’ Council for Cooperation Council States (3) Professor of Public Health, Director, WHO Collaborating Centre, Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine Imperial College London, UK (4) University of Dammam, Saudi Arabia (5) Department of Family & Community Medicine, Arabian Gulf University, Bahrain (6) Vice Dean for Clinical Affairs, Oman Medical College, Sultanate of Oman (7) Family Physician, Bahrain (8) Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia (9) Department of Family Medicine, Cairo University, Egypt (10) Senior Specialist Family Physician, Baghdad, Iraq (11) Family Physician, Amman, Jordan (12) Head of the Primary Health Care Faculty at the Kuwait Institution for Medical Specialization. (13) Assistant Program Director in Family Medicine Residency Program-Qatar.

Informed consent, privacy and confidentiality practised by doctors of a tertiary care hospital in a developing country

BACKGROUND This aim of this study was to assess the degree to which the doctors of a public sector hospital in Karachi adhere to medical ethics during their consultations. MATERIAL AND METHODS A cross-sectional study was conducted in Civil Hospital, Karachi, Pakistan, during April-June 2010. 337 patients from Out Patients Departments (OPDs) and wards were recruited through consecutive sampling. A pre-tested structured questionnaire was administered to the participants and they were asked about their demographic profile, and their doctors practices regarding obtaining informed consent, respecting privacy and confidentiality, and treatment modalities. Written informed consent was taken from all the participants. Data was analysed using SPSS version 16.0, and a p-value of < 0.05 was considered as statistically significant. RESULTS The mean age of the study population was 38.4 ± 15.0 years. There was an equal ratio of males and females. Our study showed that informed consent was obtained from 66.4% of patients. 56.9% of patients responded that they were not informed about the side effects of the prescribed medicines. 74% females were satisfied with the privacy maintained during the consultation. 64.8% were assured of the confidentiality of their information. Regarding advertisement by doctors, 46.5% of patients said it should be done. CONCLUSION There has been a marked improvement as compared with the previous practices of biomedical ethics by the doctors of this public sector hospital. However, awareness sessions should be conducted to update / improve the knowledge of ethics among doctors to help them translate their knowledge into practice.

Role of complementary and alternative medicine in cardiovascular diseases.

Introduction. This special issue focuses on the role of complementary and alternative medicine (CAM) in cardiovascular diseases (CVD). The role of CAM in healthcare specifically in cardiovascular diseases (CVDs) has been a contentious issue for centuries. With demographic shifts, urbanization, and changing lifestyles, disease burden of cardiovascular diseases (CVDs) has increased dramatically and can further increase in the future. Despite the growing popularity of CAM therapies, limited information is available regarding patterns of use of CAM therapies in cardiovascular diseases. The definition of CAM has continued to evolve. As defined by the National Center of complementary and alternative medicine (NCCAM), “it is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.” The 5 domains of CAM as classified by the NCCAM are whole medical systems (e.g., homeopathy, and ayurvedic medicine), mind-body interventions (e.g., yoga, meditation, and hypnotherapy), biologically based therapies (e.g., herbal treatments, mega-dose vitamins), manipulative and body-based methods (e.g., chiropractic therapy), and energy therapies (e.g., Reiki, and magnetic therapy). Over the last several decades, the use of CAM has become increasingly popular in both developed and the developing countries. A high proportion of patients using CAM believe CAM has remedial benefits and are safe compared to their prescribed treatments; this serves as a strong motivational factor for both present and future use of CAM. In addition, patients with CVD might be more likely to seek CAM treatments to decrease the psychological stress associated with this condition. Misconceptions regarding their efficacy have largely driven the popularity of these products whereas the adverse effects have been underreported. In disadvantaged societies where access to biomedical services is poor, the reliance on traditional/herbal medicines is more. In affluent population CAM is more used for disease prevention and health promotion. Data from the National Health Interview Surveys (NHIS) reported that 38% of adults in the USA were using CAM therapy in 2007 and among those 36% had CVD. CVD patients are often unwilling to inform their medical practitioners of CAM use and the majority of attending physicians do not discuss CAM use with their patients. Since many commonly used CAM products have the potential to interfere with the intended action of concomitant prescription medications, this could lead to serious drug interactions. In addition, the use of CAM may have negative impact on the compliance with prescription medications. A number of CAM therapies have purported cardiovascular effects; but most research on these products is either inconclusive, conflicting, or shows no benefit for their use. Several systematic reviews and meta-analysis on the effectiveness and possible side effects of CAM interventions suggest that some approaches may be beneficial as adjuncts to conventional management of cardiovascular disease, but no evidence exists to support their role as primary treatment. Dietary supplements (fish oil, coenzyme Q10, garlic, etc.) are among the most commonly used treatment modalities in patients with CVD. Fish oil supplements are accepted as a part of the treatment regimen for elevated serum triglycerides and the maintenance of vascular wall health. However, the efficacy of vitamin E has been questionable. Another intervention of CAM, that is, mind-body therapies (relaxation, stress management, meditation, etc.) have minimal side effects. However, in some countries unavailability of trained professionals in the field poses hindrance in its usage. Several styles of meditation have been tested and found to reduce blood pressure, improve heart rate, and even provide survival benefit. Evidence-based trials have been supportive of the conclusion that yoga can lower blood pressure and improve physical fitness. This one issue cannot answer all the questions regarding the safety, quality, and effectiveness of CAM therapies in CVDs. However, the main purpose of this issue is to open the communication line between patients and physicians on CAM use. It also illustrates the necessity of more rigorous researches to determine the precise pharmacological effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. Altogether, 27 papers were submitted for publication, out of which 19 papers were accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing cardiovascular diseases. There are papers on extracts of herbal plants such as Nigella sativa, extract of black chokeberry, Salvia miltiorrhiza, polyphenol and Pueraria lobata, and their cardioprotective role in treating hypertension. Ethanolic extract of black chokeberry fruits has a potential role as prophylactic agent but can also function as a nutritional supplement in the management of arterial hypertension. In addition, a study on the use of repeatedly heated oil (a common practice in Asian countries) concluded that it has the predisposing factor of atherosclerosis leading to cardiovascular diseases. Therefore, it is advisable to avoid the consumption of repeatedly heated palm oil. This special issue also has a number of reviews on the role of CAM in preventing CVD. There is a review on the role of garlic in cardiovascular diseases: treatment and prevention which concluded that garlic can be used as an adjuvant with lipid lowering drugs for control of lipids. Moreover, another evidence-based review discusses CAM and CVDs; this review recommends that more rigorous researches are needed to determine the precise physiologic effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. In addition, there is a review on Chinese herbal medications (CHM) for hypertension. This review on 10 systematic reviews found that the majority of the RCTs (randomised controlled trials) do not include primary endpoints and therefore their conclusions remain uncertain. Another review on a traditional Chinese herbal formula, Zhen Gan Xi Feng Decoction, appears to be effective in improving blood pressure and symptoms in patients with essential hypertension. The edition also includes a paper on protein kinase II signal transduction pathway that inhibits cardiac arrhythmias in rats with myocardial infarction. Another study on palm tocotrienol-rich fraction found that it was comparable to folate in reducing high-methionine diet-induced plasma hyperhomocysteinemia, aortic oxidative stress, and inflammatory changes in rats. Conclusion. The articles presented in this issue represent the recognition of CAMs role in CVD patients. Nevertheless, better education of patients and medical practitioners is needed to improve the understanding of the risks and benefits of CAM use in CVD patients. Further pieces of evidence are required to determine the impacts of CAM use in CVD patients, particularly its clinical and prognostic impact when used in conjunction with prescription medicines. An open dialogue between healthcare professionals and patients regarding intended or present CAM use is also warranted. Acknowledgments. We hope that this special issue informs and stimulates thinking about the rationale use of CAM in CVD patients. We also hope that readers will find the papers included in this issue a valuable contribution to the field and it reflects the recent trends. We would like to thank the contributors to this special issue for their insightful papers. We would also like to acknowledge the many reviewers for their detailed comments and constructive suggestions. I wish to express my gratitude to all the Guest Editors for encouraging this project throughout, and meticulously carrying out the numerous and often arduous tasks involved with this project. Waris Qidwai Peng Nam Yeoh Victor Inem Kashmira Nanji Tabinda Ashfaq

Health Care in Gulf Cooperation Council Countries: A Review of Challenges and Opportunities

This study was undertaken to review the health care status in the Gulf Cooperation Council (GCC) member states, and explore current challenges and future opportunities. Available data was acquired using databases including PubMed, Embase, and Cochrane Library. The data gathered was then combined and the expert authors in the field discussed and propose strategies to overcome the challenges. There is an increase in both population and health care needs of GCC States citizens and migrant workers. The huge emigrant population challenges the capability of the already limited available health care resources. The region is faced with a quadruple disease burden that includes communicable and non-communicable diseases, mental health issues and accidental injuries. Recent advances in technology have made breakthroughs in diagnosis and treatment modalities but with an increase in overall health care cost. Innovative and cost-effective strategies are required to cater the health care needs of people living in the GCC states. Policy makers should emphasize the need to prioritize and strengthen primary care as a matter of urgency.

Role of Complementary and Alternative Medicine in Controlling Dyslipidemia

This special issue focuses on the role of complementary and alternative medicine (CAM) in controlling dyslipidemia. Complementary and alternative medicine (CAM), also known as nonconventional medicine, includes a wide and heterogeneous array of health care practices (such as herbal medicine, acupuncture, yoga, meditation, and homeopathic medicine) that are not part of a health care system. The popularity of CAM has dramatically increased in many developed countries since the 1990s. This could be attributed to the aging of population, prevalence of chronic diseases, and concern about the adverse reaction of chemical drugs. All these aspects have contributed greatly to the worldwide popularity of CAM. In the United States, consumers spend over

The Way Forward to Public Health in Gulf Cooperation Council (GCC) Countries: A Need for Public Health Systems and Law

34 billion per year on CAM therapies spent outside the conventional health care financing system. This out-of-pocket expenditure is evidence of the belief that CAM therapies have benefits that outweigh their costs. CAM is generally more popular in most developed countries, especially in North America, Europe, and Australia. According to the 2007 National Health Interview Survey on more than 32,800 Americans, 38.2% of adults and 12% of children used some form of CAM within the previous 12 months. Dyslipidemia is an independent preventable risk factor of coronary heart disease and has been shown to increase the risk of cardiovascular mortality manyfold. Therefore, the study on various indicators and risk factors of dyslipidemia appears to be significant for future health outcomes. It is critically important to recognize the need for treatment of dyslipidemia and to institute necessary therapies to reduce the long-term risks of disease recurrence or modify the metabolic derangements that promote atherosclerosis. Drugs used in dyslipidemia may cause adverse effects if used for longer duration. Therefore patients use CAM to reduce lipids without any major side effect. The exact reasons for the popularity of CAM are complex; as they change with time and space, they vary from individual to individual and from therapy to therapy. In general, there are a broad range of positive motivations to the present popularity of CAM. Although the use and expenditure of CAM have been increased radically, the potential role of CAM in modern clinical practice and health care system seems to be limited. As the efficacy and safety have been the major concerns in the recognition of CAM and integrating it into the conventional medicine, hence, there is an urgent need to provide evidence regarding the merits of the numerous techniques of CAM. The best way to achieve this is through rigorous research. Since then, in CAM, simple answers or broad generalizations are not possible. Each of the numerous techniques has to be evaluated separately. It is necessary to bring the practice of CAM in line with evidence. The wide dissemination of its findings is also important to include CAM into the modern clinical practice. Studies have reported that CAM can be ineffective for a specific condition, but still they could be used as they do not harm the patients. Some argue that CAM should be used regardless of the results of placebo-controlled clinical trials, particularly when its use is not associated with serious risks. The main purpose of this issue is to illustrate the inevitability of researches in the field of CAM to integrate it into the modern clinical practice. Altogether, 14 manuscripts were submitted for publication, out of which 11 manuscripts got accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing dyslipidemia. This special issue includes a review that discusses the progress and perspective of studies on dyslipidemia with single Chinese herb and its monomers or effective extracts during the past 10 years. The review concludes that traditional Chinese medicine (TCM) has some beneficial effects on the treatment of patients with dyslipidemia and has less adverse effects as compared to chemical agents. However, future clinical trials are needed to be confirmed about the effects of TCM. This edition also includes a randomized, double-blind, placebo-controlled clinical trial on 50 hyperlipidemic patients. The results of this trial show that daily consumption of the fruit extract of Vaccinium arctostaphylos significantly reduces the serum levels of total cholesterol, LDL-C, and triglyceride (TG) and oxidative stress in hyperlipidemic patients. Therefore, this extract could be considered as a potential agent for treatment of dyslipidemia. Another study in this issue is on Chaihu-Shugan-San (CSS), an ancient classical formula composed of seven Chinese herbs, which found that integrated recipe might work as a significant anti-inflammatory effect in Kupffer cells. In addition, another study conducted by Han et al. on the molecular docking of echinocystic acid (EA) (isolated from G. sinensis fruits) and the effects of it on the possible targets in in vitro rat liver microsomes has been added. This review also includes a research paper which concluded that preventive acupuncture and moxibustion can significantly decrease the plasma TG and LDL, increase the plasma HDL, and prevent fat accumulation during climacteric period in rats. Moreover, a paper included is on intestinal transportations of main chemical compositions of Polygoni Multiflori Radix (PMR, originated from the root of Polygonum multiflorum Thunb.). This has been used in the treatment of hyperlipidemia in some countries for centuries. Another paper using the same herb PMR has been added to this special issue which discusses the mechanisms of the water extracts of Polygoni Multiflori Radix (PMR) and its processed products (PMRP) on liver lipid metabolism. Moreover, another paper was included in this review on propolis, which is a brownish resinous material collected by worker bees from the leaf buds of numerous plants that have strong pharmacological and biological properties. Another study analyzed the effects of acupuncture on interleukin, IL-17expression in fat excess liver on adult mice, and provided some basic evidences that the inflammatory damage of hyperlipidemic fatty liver could be restricted through acupuncture. A study in this review investigates the beneficial effects of ethanol extract of Gastrodia elata Blume (EGB) on lipid metabolism and endothelial dysfunction in a high-fructose (HF) diet animal model.