HSG is not indicated if there are no chances of blockage of fallopian tubes-Prof. Saqib Siddique

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 Proceedings of DOCTORSCON 2016 organized by PAFP

HSG is not indicated if there are no chances of
blockage of fallopian tubes-Prof. Saqib Siddique

All cooking oils being marketed in Pakistan are not pure
and most of them have palm oil base-Prof. Javed Akram

Control of asthma means that there is no need for rescue treatment,
no day time symptoms and no effects on functions- Aftab Akhtar

From our correspondent

ISLAMABAD: The first session during the Mid-Year DOCTORSCON 2016 organized by Pakistan Academy of Family Physicians at Islamabad on July 17th 2016 was devoted to Mother and Child Health. This session was chaired by Prof. Farid Zafar Principal Punjab Medical College and President of Society of Obstetricians & Gynaecologist of Pakistan along with Prof. Nasira Tasneem.  Dr. Jay Kirshnan from PIMS was the first speaker who talked about Worm infestations.

He discussed the WHO Guidelines on anthelmintic therapy and the prevalence of worm infestations in Pakistan. He was of the view that one should always ask the patients how it all started and take a careful history. Children are unfortunately too fond of junk food but we need to tell them to take enough quantity of minerals, carbohydrates and vegetables so that they can have a balanced healthy diet. Quality of sanitation is poor in our country.  Parents should also know what increased the risk of getting infections though contaminated things. Children and pregnant women, he said, are vulnerable to soil contaminated infection. He discussed in detail the soil transmitted worms. According to WHO over one Billion children population is infected with worms.


Prof. Farid Zafar, Principal Punjab Medical College and President of Society of Obstetricians &
Gynaecologist of Pakistan along with Maj. Gen. Salman Ali, Dr. Aftab Iqbal Sheikh and others
chairing the scientific session during the Mid-Year DDOCTORSCON 2016 organized
by Pakistan Academy of Family Physicians at Islamabad on July 17th 2016.

These children then suffer from iron deficiency anaemia, learning disabilities, and natural deafness. Almost 90% of children develop infection during the first five years. Younger age suffer from the maximum episodes of infections. Poverty and those living in slum areas are at greater risk. We need to improve water supply, ensure that nails of children are properly trimmed, and avoid tape worms. The children who suffer from worm infestations develop malnutrition and suffer from growth retardation. Speaking about drug therapy, he said that Mebendazole, Albendazole and other similar drugs are quite safe and effective.

Work up for Infertility by
Family Physicians

Prof. Saqib Siddique from Akhtar Saeed Medical College Lahore was the next speaker who talked about infertility work up by the Family Physicians. He pointed out that for safe pregnancy, fallopian tubes have to be healthy. Patency of the fallopian tubes is also important however there is no way to test the functions of fallopian tubes. To ensure pregnancy, one has to pick up the egg and then push them into the uterus cavity. Just one healthy sperm is good enough. For these sperms travel from fallopian tubes to the vagina is a tough journey and only a few sperms survive. It is the healthiest sperm which fertilizes the eggs and it will have the best chance of having a healthy baby. These sperms can live up to five days. Quacks and Dais dealing with these patients can introduce infection and smoking can also affect the germs.


Prof. Saqib Siddique

Speaking about investigations Prof. Saqib Siddique said that one should tailor them to suit the patient requirements. HSG is not indicated if there are no chances of blockage of fallopian tubes. He laid emphasis on counselling of the patient, patient education, reassurance, use of coital drugs. Through Intra Uterine Insemination, healthy sperms are injected with the eggs. These patients who are being worked up or under treatment should be advised to avoid smoking, alcohol, eat healthy diet and control their weight. He also talked about obstructive azospermia and said that in 85% of cases, one can get the sperms.

Gestational Diabetes Mellitus

Prof. Ghazala Mahmood from Fazaia Medical College Islamabad, talked about FIGO initiative on Gestational Diabetes. GDM, she said was on the rise. Hyperglycemia is the most common medical disorder women encounter during pregnancy. Eight countries which include India, Nigeria, Pakistan, Bangladesh, Brazil, and Indonesia have 55% GDM population. Almost 80% of burden of gestational diabetes is in poor countries. Almost 50% of women suffering from GDM are usually missed.


Speaking about management of gestational diabetes mellitus Dr. Ghazala Mahmood emphasized the importance of good antenatal care, self-monitoring of blood glucose, frequent follow up, life style management, nutritional counselling and physical activity.  As regards use of drugs, she mentioned metformin, use of insulin. If the weight of the baby is more than four Kg one must suspect GDM.  Fetal macrosomia is one of the complications of gestational diabetes mellitus. Pregnancy with good glycemic control and appropriate size of the baby should be delivered after 40-41 weeks gestation. If the baby is more than four thousand gram weight, elective caesarean section should be performed. The objective should be healthy baby and health mother. Post-delivery it is important to observe the baby for respiratory distress and hypoglycemia. Six to twelve weeks after postpartum, retest for GDM to ensure that the patient is out of risk. Advise life style interventions. Metformin helps. Child should be vaccinated and regular hospital visits should be ensured.

Polycystic Ovary Disease

Prof. Rizwana Chaudhry Prof. of Obstetrics & Gynaecology at Rawalpindi Medical College spoke about Polycystic Ovarian Disease. She pointed out that more young girls and mothers are suffering from PCO disease and it has almost become an epidemic. Its prevalence is about 20-33% and in Asian women the prevalence is about 52%. Patients come with menstrual cycle problems and in every OPD we come across about 15-20 patients who complain of PCO problems. Some of the causative factors include stress, obesity, genetic predisposition and those with history of diabetes mellitus. These patients suffer from severe acne, have hair on the face, polycystic ovary, and suffer from irregular menses. If the patient has PCO at a very young age, start him on metformin. She also talked about insulin resistance and pathophysiology of PCOS. She further stated that PCO cannot be prevented, hence treat the symptoms.  Patients suffering from PCOS can also be lean and thin and it can lead to infertility.


Prof. Rizwana Chaudhry

She then talked about chronic anovulation, menstrual dysfunctions. Male factor is also important in infertility.  PCO is a major cause of infertility. She also discussed clinical features and referred to eating disorders, depression, and increased suicide rates besides differential diagnosis. Speaking about management Prof. Rizwana Chaudhry mentioned about life style modifications, treating symptoms but emphasized that counselling of the patient was most important. The patients should be advised on weight control, if amenorrhea persists for more than three months, there is a risk of cancer but if the patient has bleeding at least four times in a year, it is safe. Stop continuous bleeding, advice physical and medical treatment and at times the drug therapy is required for longer periods. If the patient reduces weight by five Kg, there are good chances that she will conceive, she added.


Summing up the presentations, Prof. Farid Zafar commended the presenters for informative talks. He also commended the organizers for hosting such an academic activity which shows that now family physicians are also interested in such scientific activities.

Bronchial Asthma

Dr. Aftab Akhtar from Shifa International Hospital Islamabad was the first speaker in this session whose presentation was on bronchial asthma. This, he said, is a chronic inflammatory disorder. Giving details of INSPIRE study he said that it enrolled 3,451 patients from eleven countries and it showed that 21% of these patients were not well controlled. Control of asthma means that there is no need for rescue treatment, no day time symptoms and no effects on functions. Use of inhalers should be just twice a week but if there is more requirement, it means asthma is not under control. He was of the view that one should always start with a low dose inhaled steroids. He also referred to LABA, ICS followed by steroids and advocated the use of smart dose usually twice a day. If there is an emergency, one can use it again. He emphasized the importance of educating the patients to change their expectations. Everything which wheeze is not asthma. Patients should be told about it and they should also be informed that treatment of asthma requires long term use of medications.

Dyslipidemias

Prof. Javed Akram Vice Chancellor of SZABMU, PIMS Islamabad made his presentations on Dyslipidemias. He pointed out that one can reduce cholesterol through exercise, with diet as well as with some medications. However, reduction in LDL cholesterol is important for primary prevention. Increased cholesterol damages the blood vessels and it can result in heart diseases, stroke, myocardial infarction, Dementia and even Alzheimer’s disease. Plaque formation follows to total occlusion of the artery and it can rupture.  Efforts should be made to reduce inflammation and stabilization of the plaque. Use of anti-inflammatory drugs does not allow collagen to rupture. Reduction in LDL has immediate benefits in mortality reduction and this reduction in mortality could be up to 40%. Aspirin and statins are given after heart attack. These patients if overweight, obese must reduce their weight.

He laid emphasis on physical activity, smoking cessation, reducing alcohol intake, high intake of carbohydrates. Family history of high cholesterol increases the risk. Dietary modifications and life style modifications are highly effective.  Prof. Javed Akram also pointed out that all cooking oils being marketed in Pakistan are not pure and most of them have palm oil base. He also highlighted the safety and efficacy of statins. He advised the physicians to advise their patients to eat more fiber and make sure that their calories intake from fat are not more than 35%. Statins reduce LDL and increase the HDL, hence they are the drugs of choice. He reiterated that efforts should be directed at stabilizing the plaque once it is formed.  Drugs like Niacin can also be used but if one can combine statins with fibrates, it is good. Statins are the most effective, safe first line drugs. Triglycerides Prof. Javed Akram opined are an independent risk factor.

Hepatitis-C Update

Prof. Bushra Khan from Rawalpindi Medical College talked about Hepatitis-C. Referring to the survey conducted by the PMRC a few years ago, she said its overall prevalence is about 5%. In Punjab the prevalence is 6.7%, in Sindh province 5%, in Khyber PK 1.1% and in Baluchistan the prevalence is 1.5%.


About 80% of liver diseases in Pakistan, she said, are related to Hepatitis-C and 80-90% of them are of Genotype-3. An audit of admissions at the Holy Family Hospital pertaining to the last seventeen years show that 25-30% admissions are related to End Stage Liver Disease and 25-30% of deaths are due to HCV and liver diseases. With the availability of now oral medications, almost 90% cure is possible and even in case of cirrhosis, oral medication sofosobuvir gives good results, she added.

Management of Migraine

The next speaker Brig…………………… spoke on management of migraine. During the presentation, migraine, tension type headache, cluster headaches and other disorders were discussed in detail. The speaker also alluded to the relevant investigations and treatment strategy.


Speakers at the DOCTIORSCON 2016 organized by Pakistan Academy of Family Physicians
at Islamabad on July 17thfrom (L to R) are Dr. Nadeem Khawaja, Dr. Altaf Cheema,
Prof. Shahbaz Kureshi and others.

Prevention of attacks, it was stated, was important. Even simple analgesics can be used for acute attacks. However, narcotics should not be used for acute migraine attacks. Management strategy should aim at reducing the frequency of attacks by 50%. Improvements should lead to reduction in attacks and if there is no reduction in the frequency of attacks, one must review the medications. Use of anti-epileptic drugs, anti-depressants are quite useful for prevention and treatment. Good sleep is important and migraine is treatable and there is more than 50% reduction in attacks with appropriate therapy.

Summing up the presentations Prof. Liaquat who was chairing the session said that good sleep is extremely important. It reduces visits to the emergency room. He also referred to the education of patients and said that at times the inhalers are not being used properly as the patients are not adequately educated on their use. One should also check compliance of the patients with the prescribed drugs.

Management of Hypertension

Prof. Shahbaz Kureshi was the next speaker and he talked about advances in treatment of hypertension. In his presentation he referred to various guidelines available for treatment of hypertension, also talked about pre disposing factors, treatment facilities available and the sedentary life style which increases the prevalence of hypertension. If hypertension is under control it can protect all organs of the human body. JNC-VII had specially laid emphasis on life style modification and blood pressure control. Education of the patient is also important and people should be advised to reduce their intake of salt and sugar as well as fats. Physical activity has many benefits and it is recommended that one should go for forty five minutes’ walk seven days a week. We the doctors, Prof. Shahbaz Kureshi opined, must become role model and start practicing what we preach to our patients.


Lower the blood pressure, better it is. CAD patients, he said, should be careful. Patients should be advised on compliance with the therapy and physicians should try to reduce the number of pills the patients have to take which will also improve compliance with therapy. If the patient is suffering from hypertension as well as diabetes mellitus and kidney disease, one must select appropriate antihypertensive medications with proper combinations. Now Fix Dose Combinations are also available which are quite safe and effective. It is often observed that monotherapy is not adequate to control high blood pressure and one often has to prescribe two to three drugs. He concluded his presentation by stating that Fix Dose Combinations are much better for compliance and management of hypertension. They are also most cost effective, with least side effects and less complications.

Workshops on Diabetes

In the afternoon there were workshops on Diabetes and the topics which were discussed included Diabetic Peripheral Neuropathy, Diabetic Nephropathy, Macro vascular complications of diabetes and How to Initiate, Titrate and maintain Insulin therapy.