Political will, massive screening and engagement of non-specialists in treatment can help eliminate HCV- Saeed Hamid


PSIM Conference Proceedings
Political will, massive screening and
engagement of non-specialists in treatment 
can help eliminate HCV- Saeed Hamid
Pleuroscope has revolutionized the practice
of Pulmonary Medicine-Prof.Saqib Saeed
Treatment of NASH requires multidisciplinary
approach-Prof. Zaigham Abbas

LAHORE: We have all the tools available in Pakistan to eliminate Hepatitis-C. What is needed is massive screening, engagement of non-specialists in the treatment and political will by the government. This was stated by Prof. Saeed Hamid from Aga Khan University Hospital while make a presentation in HCV Treatment Update during the session devoted to Liver and GI Diseases at the Pakistan Society of Internal Medicine conference held here from March 12-15th 2020. This session was chaired by Prof. Ghias Un Nabi Tayyab.

Continuing Prof. Saeed Hamid said that we need to go to the community to serve people. The strategy should be to screen more and treat more. These days the role of specialists in treatment of Hepatitis-C, he opined is changing. We need to educate the people and develop training programmes. Treatment of HCV can be termed as the medical miracle of the 20th century.

Tracing the history of HCV treatment, Prof. Saeed Hamid said that until 1991 there was no treatment. Then came the era of interferon therapy. Then came the NS5A inhibitors and currently numerous DAAs are available for its treatment. Sofosobuvir was the first oral drug available for the treatment of HCV. Later on many other drugs became available. At present treatment of HCV cost about Rs. 1500/- per month. WHO recommends that patients over the age of 18 years use DAA regimens? Without cirrhosis the recommended treatment is for twelve weeks. For compensated cirrhosis, other combinations are available which offer 96-100% cure rate. Determining status of cirrhosis is important. HCV prevalence in Punjab is 9%, Sindh has 5% which means that we have about 8-10 million infected patients. HCV is the biggest cause of liver cancer. Fibroscan can make the diagnosis of severity of disease. There are simple lab based tests. Some computer based programmes are also available to help make diagnosis.

Dr. Kamran Hassan discussed the management of Hepatitis-B. Treatment of this infection, he opined, needs special knowledge. HBeAG positive indicates active replication of viruses. HCC patients can have HIV co-infection. Patients with cirrhosis need to be treated. He then discussed the indications for treatment. Drugs available for treatment include Tenofovir, Entecavir and Peg Interferon is also available. He also talked about the treatment of HBV in special groups of patients. For acute HBV infection Peg Interferon is contraindicated.

Prof. Zaigham Abbas from Karachi discussed Update on NAFLD. He pointed out that about 15% of our population is suffering from fatty liver disease. Prevalence of overweight and obesity is about 25%. Metformin has a protective effect against HCC. Other treatment modalities include reducing the stomach size and weight reduction surgery. Treatment of NASH, he said, requires multidisciplinary approach. No single drug is effective. Earlier Prof. Wasim Jafri from AKUH Karachi made a presentation on Hepatitis-C elimination by 2030- a realistic goal.

Pulmonary Diseases Session

Prof. Saulat Ullah Khan chaired this session. Prof. Saqib Saeed from KEMU Lahore was the first speaker whose presentation was on Role of Pleuroscopy in diagnosis of chest diseases. He pointed out that 25% of chest diseases are related to pleura and conventional methods of treatment are becoming obsolete. During 2019, out of 1664 patients, 20% were of COPD and pleural effusion. Thorascopy offers diagnostic and therapeutic modality in 90-95% of pleural diseases. It is a minimal invasive procedure and it is a window to pleural space.

Speaking about the historical background he referred to the availability of semi rigid Thorascope which is more flexible. It has a small work channel, can be used for diagnosis and therapeutic purposes. In a bronchosopy suite, it can be done by a trained pulmonologist as a medical Thorascopy. Medical Thorascopy and VATS are over lapping. He then discussed the diagnostic and therapeutic indications. Lack of pleural space and unstable hemodynamic position, he stated, was a contra indication for this procedure. Dedicated ultrasound unit, he said, is essential to undertake this procedure. It is advised to stop Warfarin five days before the procedure. He then showed the safe triangle for the site of entry in the chest and also showed some malignant lesions besides discussing the likely complications in detail. The reported mortality with this procedure is 0.01% hence it is a very safe procedure. He then gave details of Thorascopy procedures performed in their unit at KEMU Mayo Hospital from September 2015 to 2017. A total of two hundred forty four procedures were performed in patients between the ages of 55-62 years of age. It included 171 of adenoid carcinoma, 39 of tuberculosis, 19 were of empyema and seven cases of B cell lymphoma. His conclusions were that Pleuroscope has revolutionized the practice of pulmonary medicine. It is a safe and effective procedure. We did not take even a single patient to the operation theatre but one should be prepared to take the patient to the OT if need be.

Bronchial Asthma

Dr. Salman Ayyaz discussed what is new in Asthma. This, he said, is a chronic disease worldwide and its prevalence in Pakistan is estimated to be 7-8%. About 15% suffer from allergic rhinitis and asthma. These patients have recurrent episodes of dry cough. They suffer from troublesome cough at night and have breathing difficulties. In case of wheeze, chest tightness one must rule out asthma. He also talked about the level of asthma control and said that we wish to keep the patient in well controlled. He then discussed the use of inhalers, compliance, and use of correct device and correct technique which must be explained in detail to the patient. Uncontrolled asthma may be COPD. In such situation it is important to reassure the patient, take care of the risk factors, consider treatment step up and refer to a specialist for severe asthma clinic. Those patients taking Beta Blockers and ACE Inhibitors, asthma will not be controlled. Treat GERD and take care of NSAID allergy. If treatment is good with compliance the patients will keep on coming to you hence take care of the above. He further stated that patients at risk of asthma related death should be identified. Treatment should be reviewed at one to three months interval. During pregnancy review treatment at four to six weeks interval. Stable patients can be followed up at three months interval and then consider step down treatment. Advise physical exercise and smoking cessation. He also talked about the management of occupational asthma. It is important to avoid medicines which worsen asthma. Sublingual immunotherapy is helpful in patients who are sensitive with allergic rhinitis. He also gave details of the available biologic drugs, some of which are currently available while some may become available in the days to come. Bronchial thermoplasty facilities are available at some centers, he added.

Prof. Safdar Malik spoke about imaging in lung diseases and discussed in detail the role of 3D in reconstruction. He also gave details about the findings on Chest X-ray vs CT of Chest and described the indications for MDCT Chest. He then showed chest tumours, lung cancer diagnosis and its staging, characteristics of intestinal lung disease, virtual bronchosopy, patchy ground glass shadowing, aortic aneurysm and aortic dissection. He also showed interesting informative slides of CT Angio of pulmonary hypertension, pulmonary artery embolism, and patent stent in LAD and said that some patients may have extra cardiac pathology.

Sleep Apnea

Dr. Irfan Malik speaking about obstructive sleep apnea said that OSA is under diagnosed and ignored in Pakistan. He discussed in detail the sleep apnea syndrome and untreated OSA. Sleep, he said, involves brain as well as body. It is a dynamic process and one needs about seven to nine hours of good sleep. Diabetes may become uncontrolled in case of sleep for more than nine hours. He then spoke about sleep related breathing disorders like snoring, airway resistance. Majority of the patients of sleep apnea, he said, remain under diagnosed. He then discussed sleep fragmentation, wake up and disturbed sleep. Central sleep apnea is less than 1% while 90% is obstructed sleep apnea. Its prevalence in general population is estimated to be 1-5% and in UK its prevalence is 0.3%. In India according to studies the prevalence of OSA is 9.3% and it may be as common as in Pakistan. We have malignant hypertension and prevalence of obesity is increasing which at present is estimated to be 7-10%. As regards associated diseases hypertension accounts for 35%, Atrial Fibrillation 49% and 59% of the patients have pace makers. He also discussed the various stages of sleep including REM sleep. Enlarged tonsils can be a cause of sleep apnea and snoring, he added.

Kaleidoscope of
Medical Career

Prof. Tariq Waseem moderated this session in which the panelists included Dr. Tanzeem Haider from UK, Dr. Ali Hashmi, consultant psychiatrist who was trained in USA, Prof. Javed Hayat Khan, Dr. Asif, and Prof. Nasir Shah from UHS and Prof. Bilquis Shabbir from KEMU.

Describing career opportunities in United States Dr. Ali Hashmi from KEMU said that he remained in USA for fifteen years and joined KEMU in 2010. USA has a good system of structured training but now it has become extremely difficult to settle there. It is also very expensive and it may cost from eighteen to twenty thousand dollars. KEMCANA does offer some help and assistance in the form of scholarship. Cost is the biggest issue apart from the visa problems. It is difficult to get in the training system in USA and then it is also difficult to attract those people back to Pakistan after they finish their training. To get into the system one also needs referral from some US trained physician, he added.

Dr. Ali Hashmi (5th from right) speaking at the panel discussion during the PSIM conference.
Also sitting on the dais other members of the panel are Prof. Nasir, Prof. Bikaram,
Prof. Tanzeem Haider Raza, Prof. Bilquis and others.

Dr. Asif participating in the discussion pointed out that after Brixt, there will be many job opportunities for Pakistani doctors in UK. One has to start with FY-I level, UK provides excellent training but the time period is much longer as compared to United States. MRCP, he further stated, was not a consultant degree but it is start of the training. Dr. Tanzeem Haider Raza said that there is nothing like serving your own country. UK system provides best training but it is advisable to have some years of clinical experience in Pakistan before you go to UK for higher training. Now MRCP-III Paces exam is starting in Pakistan from November 2020 which will be a great help for Pakistani doctors who wish to have British qualifications.

Prof. Bilquis Shabbir said that she tried many times but unfortunately she could not get Visa for USA but then fortunately she got an academic job in Pakistan which also proved to be a blessing in disguise as she could look after her ailing father who passed away recently. It was a great satisfaction. She opined that one can work successfully in Pakistan and this is the time that we should serve and give back something to Pakistan.

Dr. Javed Hayat Khan described the situation in Middle East which offers some jobs. There are quite a few very good state of the art healthcare facilities in Saudi Arabia and some other Gulf countries. Prof. Nasir Shah highlighted the importance of Family Medicine which offers good opportunities for a successful career in Pakistan as well.

Prof. Bikharam Devrajani Vice Chancellor Liaquat University of Medical & Health Sciences in his concluding remarks said that they started MS and MD programme at their University along with FCPS in 2002. There is no compromise on quality of training. We have a structured training programme for MS and MD as well. We can start two years rotation programme for all those doing MS, MD or FCPS. Many doctors serving abroad would like to come back after training if we can provide them job opportunities.

The Nephrology session was chaired by Prof. Aizaz Mand a noted Nephrologist. The topics discussed in this session included Diabetic Kidney Disease by Prof. Shafiq Cheema. He highlighted the importance of prevention which he opined should start from control of hypertension, diabetes and facilities for this must be made available at the primary physicians and internal medicine level. Now renal diseases, he further stated are getting importance in medical education as well.

In his concluding remarks Prof. Aizaz Mand said that SGLT2 are quite effective but we must keep in mind the likely complications. It is also very expensive and when these drugs are used more, we will come to know more about their side effects.

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