Clinical Proceedings of PSIM’s Mid-Summer Conference

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Clinical Proceedings of PSIM’s 
Mid-Summer Conference

MUZAFFARABAD (AJK): The session devoted to Hematologic disorders during the PSIM’s Mid-Summer conference held here from September 3rd to September 5th 2020 was chaired by Prof. Abdul Khaliq Awan alongwith Prof. Tariq Masood and Dr. Rubina. Prof. Azizur Rehman was the first speaker in this session who talked about deciphering the hidden secrets of CBC.

He pointed out that all of us do order these tests but it is important to decipher the hidden secrets of CBC. It provides wealth of information but its interpretation is important which can now be made by artificial intelligence as well. We must know what investigations are needed in case of iron deficiency anaemia. We do not see Vitamin B-12 deficiency, Folic Acid deficiency in every patient. He then talked about thrombocytopenia, increase in platelet, limitations and if everything does not fit into clinical judgment, one need to rethink and look at it again. CBC, he opined, will give you lot of useful information.


Dr. Farah Bashir and Prof. Munir Azhar jointly made the next presentation on Autoimmune Hemolytic Anemia in SLE and its association with systemic features. It was pointed out that it can present with life threatening diseases. AIHA is not uncommon cause of anaemia but it is more common in males and it is not associated with arthritis or nephritis.

Brig. Altaf Hussain from CMH Bahawalpur discussed Visceral Leishmaniasis which is caused when the sand fly bites the human. He then referred to TH1 and TH2 and highlighted the needed investigations which include culture, Elisa, PCR test. Culture is not well established in Pakistan. Rapid test is not popular which has not stood test of time. His presentation was based on fifty two male and nine female patients. Most of the patients were diagnosed after a mean period of forty five days when they got infected. Young patients he said, will have high grade fever. After treatment for five to six days, fever got settled. Another finding of the study was that 82% of patients were diagnosed in non-winter season. Fifty two patients had complete cure while nine had satisfactory response. None of the patients who was treated was resistant to treatment. His conclusions were that early diagnosis and proper treatment will reduce transmission, prevent morbidity and mortality.


Prof. Munir Azhar from QAMC Bahawalpur speaking at the PSIM’s Mid-Summer
conference held at Muzaffarabad recently. Also sitting along
with him on
the dais is Prof. Sajid Abaidullah.

Major Gen. Pervaiz Ahmad gave an overview of bone marrow transplantation. Stem cell therapy, he said was a rescuer transplant to replace bone marrow when the treatment of cancer has destroyed patient’s bone marrow. He then referred to the indications for allogeneic stem cell transplant. Autologous transplant, he said, is more common in the West but not in developing countries. Aplastic anaemia, thalassemia, marrow failure syndrome, AML and other therapeutic consideration were discussed in detail. He also talked about donor availability and compatibility. Cord blood, he said can be used. He then spoke about post-transplant work up. Infections he pointed out are the major killers, it is difficult to prevent and reducing infection is expensive. He also discussed the issues related to lack of Bone Marrow Registry in Pakistan, Bone Marrow Donor registry was also not available. As per HOTA ordinance, any transplant being done has to be done from related donors. For BMT live related donor is needed in Paksitan though non-related donors are being used all over the world except Pakistan. Drugs needed are not available and it is the poor who suffer the most. These are the issues which need to be looked into by DRAP which should ensure the availability of these drugs. We have a few BMT centers in Pakistan. In case of aplastic anaemia, good results are possible in young patients, he added. Col. Raheel Iftikhar was the next speaker whose presentation was on Hematologic manifestations of systemic disorders.


The next session was sponsored by Servier Pharmaceuticals. It was jointly chaired by Prof. Zaman Sheikh and Prof. Tariq Waseem. Prof. Javed Akram President PSIM was the first speaker who talked about implications of DIARAMDAN in clinical practice. He pointed out that despite being high risk diabetics still fast hence it is important for us physicians to make sure that the diabetics can fast safely. He made a passionate plea not to stigmatize the people suffering from diabetes or hypertension. We need to explain the dangers and listen to the patients. Studies have shown that almost 50% of Type-I and 86% of those suffering from Type-2 diabetes do fast. About 56% fast every day. CREED study had showed that 70% of these diabetics fast daily. The major problem is after Iftar because we tend to take two to three meals after Iftar. We consume too much too quickly after Iftar. Hypoglycemia is the most dreaded complication. Control of Hypo and Hyperglycemia will allow us to advise the patients to fast. There is risk of thrombosis and dehydration. If we educate our patients, they won’t suffer from Hypoglycemia. If the patients had no episode of hypoglycemia pre-Ramadan they will have no Hypo during Ramadan.


Prof. M. Ishaq

Continuing Prof. Javed Akram said that we must share the investigations done. Jamia Ashrafia has given a Fatwa that Insulin injection will not breakfast. We need to do risk quantification on individual basis. We need to ensure that patients comply with medications. Prevent complications and target organ damage. If the patient has a history of three to four episodes of Hypo Pre-Ramadan, they should be advised against fasting. Patients must know what hypoglycemia is and learn home blood glucose monitoring. Fasting increases performance. Patient education remains the key to safe fasting. It is the duty of physicians to make fasting safe for the patients. Doctors should make themselves available to the patients during Ramadan. Pre-Ramadan education of patient will reduce the chances of hypoglycemia. About 50% of patients will not need any dose adjustment with drugs but insulin dose will have to be adjusted. He then shared the findings of DIA-RAMADAN multicenter study which showed that patients on Gliclazide had much less episodes of hypoglycemia. One need to start taking Gliclazide three months before Ramadan. This study enrolled 1214 patients with average HbA1c of 7.6. None of the patients in the study had a serious hypoglycemia. There was reduction in weight gain, fasting blood glucose also decreased.

Prof. M. Ishaq discussed the rationale of triple dose combination in the management of hypertension. Optimal control of blood pressure, reducing it to target levels will reduce morbidity and mortality. We need to create awareness and start treatment immediately. Compliance with drug therapy, Prof. Ishaq said, was a major issue as sub-optimal control leads to increased morbidity and mortality. Combination of Perindopril, Indipamide and Amlodipine in single pill increased compliance with therapy. It is important to assess the risk of complications in patients. Our goal should be reduction in blood pressure, reduction in target organ damage and metabolic syndrome. To ensure that we must start treatment on time. Once kidney disease is established, it is irreversible hence one should be careful. Most patients need three drugs to control hypertension. There is sufficient evidence that with the use of triple drug therapy, compliance improves and it also results in reduction in morbidity and mortality. It will also reduce IHD and chances of stroke. Combination of Diuretics, ACE inhibitors and Calcium Channel blocker is highly effective, safe and well tolerated. The likely side effects include cough, edema and hypotension. The incidence of cough with this combination which was stated to be 0,08% did raise some healthy discussion and most of the participants were of the view that this cough incidence seems to be under reported. Cough with ACE Inhibitors is a major side effect.


In his concluding remarks Prof. Zaman Sheikh said that there are certain grey areas. Even if the blood glucose is 70 and no symptoms, the patients can be allowed to continue fast.

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