Goal of management in Back Pain is relief of symptoms, maintaining the functions and improvement of quality of life- Dr. M. Ahmed Saeed


 International Medical Conference at FMH

Goal of management in Back Pain is
relief of symptoms, maintaining the
functions and improvement of quality
of life- Dr. M. Ahmed Saeed

Monotherapy will provide seizure control in 70%
of cases. It is also better tolerated and leads
to better compliance-Prof. Noor Ali Pirzada

Feedback is often not well received. We all must
be receptive to feedback, develop and promote
a routine feedback culture- Dr. Amina Ahmad

LAHORE: Dr. Amina Ahmad a noted medical educationist was the first speaker in the afternoon session on the Day-One of the International Conference on General Medical Updates organized by FMH in collaboration with Nur International University on February 27th 2019. The topic of her presentation was Work Based Assessment. She discussed in detail the training based modules with emphasis on Knowledge, Skills and Attitudes Competency based Modules, she stated, is becoming more and more important. In this the important core ideas include how a doctor behaves, his attitudes with patients and his professional colleagues.

Dr. M. Ahmad Saeed

ACGME competencies module includes patient care, medical knowledge, professionalism, communication an d inter professional skills, patient based and system based learning etc. On the other hand the Canadian Model expects the doctors to be good manages, scholars, collaborate with others, medical experts, professional, good at communication skills besides being a health advocate etc. Competency Based Medical Education requires that one acquires mastery in every field. All these programmes are learner centered. Professional ability of the learner improves as one goes up in the Miller's triangle Pyramid which covers Knows, Knows How, Shows How and Does. The first two are related to cognition while the last two are related to Behaviour. Knows how means that one has deep understanding. Direct Observation of Clinical Skills is related to professional assessment which is a work based real life assessment. She then also referred to the Mini Clinical Evaluation Skills Exercises. Decision making skills are tools when you have to make the diagnosis. Training programme indicates that one must have ensured reasonable expertize at the end of the programme when one graduates. Assessment for learning is to give feedback which is very important. Dr. Amina Ahmad was of the view that feedback is often not well received. We all must be receptive to feed back. We need to develop and promote a routine feedback culture. Listening skills is also very important but meta-analysis studies have showed that the doctors interrupt the patient just after listening for sixteen to seventeen seconds.

Dr. Muhammad Ahmad Saeed consultant rheumatologist was the next speaker whose presentation was on Back Pain. He discussed at length the management guidelines. Back Pain, he said, is very common and almost every one after the age of fifty years have an episode of back pain. About fifty three causes can be listed for muscular spasm injury and disk herniation. He then presented a few cases and discussed their management. The first patient was a fifty years old male suffering from low back pain for two weeks. The pain he said, got worse with activity but was relieved on rest. The pain was radiating to the whole leg, the patient also complained of numbness of right foot, had positive SLR, and suffered from weakness of leg. Redness, swelling, trauma he pointed out are some of the red flags.

Dr. Amina Ahmad

The second case he presented was of twenty four years old male who reported with pain of joints. It improved with exercise. His age was less than forty years. He was diagnosed to be suffering from inflammatory back pain and managed accordingly. The third case was thirty two years of old who was being treated for Multi Drug Resistant TB for the last three years. He was totally crippled. He had bilateral, hip joint replacement. He was suffering from Arthritis associated with IBD, reactive arthritis. He then talked about psoriatic, juvenile SPA and undifferentiated SPA. Good history and physical examination Dr. Muhammad Ahmed Saeed remarked are the gold standard. Careful examination and red eye history showed psoriatic area. Vasculitis gives you a clue to diagnosis. He then talked about referral strategy for inflammatory type back pain. The goal of management in such patients, he stated is relief of symptoms, maintaining the functions and improvement of quality of life. Suppression of inflammation with anti-TNF inhibitors can inhibit new bone formation in AS. There is a window of opportunity in disease modification. He highlighted the recommendations related to treat to target, clinical remission and disease inactivity stage. ASDAS score is useful in active disease and disease in remission. NICE guidelines on AS were also highlighted.

Speaking about DMARD options, Dr.Ahmed Saeed highlighted the importance of using optimal dose of NSAIDs, physical therapy with regular exercise. Biological DMARDs are very effective but they are also expensive. One also has to be careful about the GI, renal side effects. One should use regular dose of NSAIDs and combine it with PPIs to take care of gastric side effects. Effective suppression of TNFI stops the progression of disease. Surgical management may be indicated in some patients. Chairman of the session Dr. Abid Arshad in his concluding remarks said that chronic low back pain is seldom seen in patients below forty years of age and MRI can help in diagnosis.

An Update on Epilepsy

Prof. Noor Ali Pirzada from USA was the next speaker who gave an update on Epilepsy. He discussed in detail the clinical features, classification, its pharmacological and surgical treatment besides epilepsy in pregnancy. Epilepsy he opined was the fourth most common neurological disorder after headache, dementia and stroke. Its prevalence is one to two percent of the population. It results from excessive electrical discharge from the brain. Recurrent seizures are called epilepsy. Anyone who has two unprovoked seizures in twenty four hours is labeled as epilepsy. Seizures can be classified into partial, simple, complex partial, secondary generalized and generalized. In generalized seizures there is loss of conscious.

Prof. Noor Ali Pirzada

Speaking about the causes of epilepsy Prof. Noor Ali Pirzada said that almost 66% are idiopathic, 11% have some vascular disease and about 4% are congenital. Partial seizures are most common. He then discussed at length the clinical features of different types of epilepsy i.e. complex partial seizures, petit mal which last for few seconds, myoclonic with jerks. Tonic and chronic tonic seizures results in stiffness of the whole body. The best investigation, he opined was good history. EEG will not give you the answer. In 50% epilepsy patients the EEG is abnormal hence EEG should not be preferred. However, serial EEG will improve the diagnosis to 90%. Ten percent of patients will never show intractable abnormalities. He then showed some abnormalities seen on the MRI. Medical treatment benefits many patients but it has some potential drawbacks. Recurrence of seizures can be noted. The disease carries with it the social stigma. Cost of medications is another issue. However, he made it clear that not every seizure needs to be treated for long time. Provoked seizures have an obvious cause like alcohol withdrawal. Some drugs can also provoke seizures. Remove the provoking cause and these patients will not require prolonged treatment.

As regards unprovoked seizures, there is a 30-40% chance that they will come back while 70% won’t recur. Unprovoked seizures do not need treatment for too long. Patients who have two unprovoked seizures in twenty four hours should be treated. Before starting treatment it is essential to determine the seizure type as it will determine the course of treatment. Start with one drug with full dose, titrate to tolerable dose. If it is not effective, start second drug and wait for two to three weeks to see its effects, then use combination therapy. Monotherapy will provide seizure control in 70% of cases. It is better tolerated and also leads to better compliance. It is important that one selects the most effective drug for seizure types. Consider side effects of each drug. In patients with depression, migraine prefer valproate. In obesity as well as pregnancy avoid valproate. Consider convenience dosing. The second generation Anti-epileptic drugs include Lamotrigine and others new preparations but they are not better. There are drugs for partial epilepsy. One can use a combination of two anti-epileptic drugs with different sites of action. In some patients Phenobarbitone and phenytoin is not well tolerated. It is important that one choses the right drug for the right type of epilepsy. Starting and maintenance dose of different anti-epileptic drugs were also discussed in detail. Adverse effects of anti-epileptics include rash, Steven Johnson syndrome, acne, gum hypertrophy, tremor, weight gain, hair loss, Ano renie, weight loss, anger and irritability.

Some patients who fail on medical therapy may be helped surgically. Patients with focal epilepsy respond well to surgical therapy one can remove the seizure focus. Palliative surgery is also helpful to reduce seizures and almost 50-70% of patients become seizure free and the rest 30% also show some improvement. Vagus nerve stimulation is another treatment modality which is being used since 1997. So far more than hundred thousand implants have been inserted in patients. Right Vagus nerve is not used. About 50% reduction in seizures is considered the bench mark for success. He also talked about RNS neuro stimulator. Prof. Noor Ali Pirzada concluded his presentation by stating that epilepsy is a common disorder, it has its social and economic impact. New drugs are better tolerated. Neuro stimulation and surgery have a positive effect and improve seizures. With better diagnosis and treatment, epilepsy patients can have a good quality of life. Responding to questions he stated that surgery was not indicated in partial epilepsy but neuro stimulators are recommended.

Dr. Nuzhat Ashai from United States was the last speaker in this session who discussed latest guidelines on management of hypertension with special reference to SPRINT guidelines and impact of the new guidelines. She pointed out that JNC-1 Guidelines were announced in 1976 and the JNC-8 Guidelines were made public in 2013. American College of Cardiology and American Heart Association have their own guidelines.

Dr. Nuzhat Ashai

All these guidelines shows that there is significant overall reduction in morbidity and mortality, cardiovascular events with treatment. Intensive BP lowering offers mortality benefits during short period of time. There is positive effect in CKD patients as well. The SPRINT document is based on ACC-AHA guidelines. She laid emphasis on accurate measurement of blood pressure which was essential before starting treatment. One should be careful about the faulty BP measuring techniques, use of proper cuff size should be ensured. Position of the patient while the BP is being measures is also important, their arm should be at the heart level. It is important to measure BP of both arms on first visit and then take the arm which shows high BP. A patient should be labeled as hypertensive if there is high blood pressure on three visits with a gap of one or two weeks. ABPM is preferred in United States. Blood Pressure measurement of 120/80 is considered normal. SBP of 120-129 is considered pre-hypertension while 140/90 will need life style modifications. Reassure the patient for three to six months. In diabetics the desired BP is 130/80. Those with diabetes, chronic kidney disease or patients with more than sixty five years of age should be started with one drug, advice on healthy diet, weight loss, reduced intake of sodium and regular exercise.

Continuing Dr. Nuzhat advised the participants to calculate the ten years risk of cardiovascular events in the patients. In case of no CVD, achieving target of 130/80 is not necessary. Thiazide diuretics and calcium channel blockers are considered as the first choice in treatment of hypertension. ACEIs and ARBs are also safe and effective but one should not use ACEIs and ARBs at the same time. Those who cannot tolerate ACEIs should be put on ARBs. In patients with renal artery stenosis, renal transplantation CCBs are preferred. For guidelines, cost and real life experiences are important. Situation may be different in different countries. She further added that guidelines are not mandatory. It should be the clinical judgment which should guide the treating physician on treatment. It is hoped that ACC will review its guidelines. Diuretics and CCBs are most effective and also have less side effects, she added.