Inhaled steroids is ideal treatment for management of Asthma- Prof. Nadeem Rizvi

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 PSIM Conference Proceedings-IV

Inhaled steroids is ideal treatment for
management of Asthma- Prof. Nadeem Rizvi

In stable COPD patients long acting
bronchodilators
 are preferred - Dr. Ali Zuberi

KARACHI: Prof. Nadeem Rizvi former Head of the Dept. of Chest Medicine at JPMC Karachi was the first speaker in the session devoted to Pulmonology during the Third Annual Conference of Pakistan Society of Internal Medicine (PSIM) held at Karachi during March 2022. The topic of his presentation was Asthma Management beyond Prescription. He pointed out that globally about three hundred million people were suffering from Asthma. This number is increasing by 20-25% after every ten years. Local prevalence of asthma is not known in Pakistan as no local data is available. However it is generally believed and according to Pakistan Chest Society, its prevalence would be about 5% of all adult population. Its prevalence is high in males. There is still some confusion about its pathophysiology.


Prof. Shamsuddin (Centre) along with Prof Khalid Mahmood charing one of the
scientific session during the PSIM 3rd Annual Conference held at Karachi.

Exposure to allergens, genetic predisposition, environmental factors are some of the factors responsible for this disorder. Clinical diagnosis is the best. Breathlessness, wheezing history, physical examination, and peak flow meter reading are helpful in making diagnosis. Peak flow meter is easily available for less than one thousand rupees however, Family Physicians were still not using it to diagnose asthma. They can also be used to check response to treatment. Some patients may not be taking bronchodilators, give them oral steroids. Some patients may not complain of any problem during exercise but when using stairs to come down, they feel breathlessness. Education of these patients, Prof. Nadeem Rizvi remarked was the main issue. There are drugs for control of asthma and drugs for relief of symptoms. Both these drugs are available in Pakistan. Use of inhalers is very useful but most of the patients are on tablets or injections. He emphasized that inhaled steroids is ideal treatment for management of Asthma. He also referred to asthma control therapy and then stated that all patients need inhaled steroids. However, in practice, we see most of the patients are on bronchodilators. Which inhaler to use and how to use it was important? Prof. Nadeem Rizvi clarified that it is a myth that some families consider that it is habit forming. We need to educate the patients. Empathy and education are extremely important. Drugs, he further stated, will only work when they reach at the site.


Continuing Prof. Nadeem Rizvi referred to the use of spacer devices. Nebulizers, he opined, are over used in Pakistan. One should not change the device again and again, he remarked. Responding to questions during the discussion he said we do prescribe PPIs. Allergic bronchitis is also asthma and these patients have to take treatment on long term basis. Cough syrups, he said are misused in Pakistan. It is a big market. In UK only three cough syrups are available. One should use expectorants rather than cough suppressants, he added.

Dr. Ali Bin Sarwar Zuberi was the next speaker who talked about Diagnosis and Management of COPD in 2022. COPD, he pointed out was the third leading cause of death worldwide and it is still increasing. It is a preventable and treatable disease. Patients have persistent respiratory symptoms in COPD which accounts for 5% of all global deaths. Atmospheric pollution is an important risk factor. Fatigue is common in COIPD in adults and it is also more common in male after forty years of age. Spirometry can confirm COPD diagnosis. He also referred to COPD assessment test using CAT scoring. He made it clear that it was crucial to stop smoking as drugs won’t work in smokers. For management of COPD, ABCD assessment tools are important. In stable COPD patients long acting bronchodilators are preferred. Oral medications have more side effects as compared to inhalers. Theophylline’s are not recommended except in a few selected cases. Potential risk of steroids must be kept in mind. Vasodilators, he said, do not improve the outcome but they may worsen the oxygenation. He also talked about indicators for non-invasive mechanical ventilation. Comorbid are common in COPD, he added.


Some of the delegate to PSIM 3rd Annual Conference held at Karachi photographed along
with Prof. Ejaz Ahmed Vohra Patron PSIM (Centre) Prof. Javed Akram President PSIM and
Prof. Aftab Mohsin Chairman of the Organizing Committee.

Prof. Brig. Jamal Ahmed, from Rawalpindi spoke about Multi Drug Resistant TB. Tuberculosis, he said, was the 13th leading cause of global deaths. During 2020 1.5 million patients died due to tuberculosis. Pakistan has the fifth highest burden of multidrug resistant tuberculosis. Only 55% of patients were getting treatment as per WHO guidelines. The prevalence of MDR TB was 3-6% in Pakistan. About 18% of primary tuberculosis patients develop MDR. During 2019 the number of multi drug resistant TB patients in Pakistan was estimated to be twenty five thousand. If the disease keeps on progressing with treatment, it should be suspected as MDR TB. Speaking about its symptoms he mentioned fatigue, weight loss, shortness of breath. Line probe assay, chest X-ray, Gene Expect test are useful for diagnosis. He then discussed the safety and efficacy of various drugs in the treatment in long term regimen. One can initiate treatment for six months and then follow it up for twelve months if need be. Surgery is indicated after two months of treatment in patients who do not have extensive disease but it is not recommended in bilateral disease. Facilities for treatment of multi drug resistant tuberculosis, he sated, are available at thirty one sites all over the country. His advice to the healthcare professionals was to refer the patient to those healthcare facilities which have proper treatment facilities. Patients who are lost to follow up and low detection rate were the major challenges. App is available on the net regarding WHO guidelines for management of tuberculosis. We need to do legislation for isolation which is important for MDR cases at last for one month. Recurrent infections occurs in the cavities.

Behaviour Sciences/Medical Ethics Session

Prof. Mowadat H. Rana was the first speaker in this session who spoke about Myth and realities about Evidence Based Medicine. These days students, he opined were much more educated and informed. The whole world is now available on the smart phone which is easily accessible. Evidence Based Medicine, he opined, was not the last word. There was a time that TCAs were excellent drugs for depression and OCD but no more. EBM, he pointed out, was based on RCTs and Meta-Analysis but it does not take into account the difference in design of these RCTs. Now everything is being challenged. Individual patient’s values are not covered in RCTs. It does not cover crisis situations like Covid19 pandemic. We see the transplantation of western mode of medical care. There is over emphasis on health economics. This is cost based approach. These RCTs covers most but not all issues.

In the RCTs, he said, there is limited use of unproven innovations. It promotes equity, there is limited variation. Pharma industry has a role to influence evidence. It is being questioned whether RCTs were less biased and best evidence. Funding sources might also introduce bias. Instead of retesting the western evidence, let us generate local data. He encouraged the initiation of clinical trials to generate hypothesis. Use of Evidence Based Medicine alone or in isolation is not recommended. Study design is important. Let us create balance between cost and care. His take home message was that let us prefer APPNA Model over Puraya Model. Let us look at international guidelines, try to understand pathophysiology of the diseases, take into account patent specific clinical needs and realities. Take into account the cultural values, norms, clinical experiences and judgment and give informed choice to the patient and families, he remarked.

Prof. Muhammad Tariq from Aga Khan University spoke on Innovations in Medicine. He pointed out that clinical teachers are different form clinicians. Clinicians diagnose the disease for which we need to train them. Artificial intelligence is machine learning it is fed with lot of data which is then used for making diagnosis and make treatment plan. He then referred to traditional medicine, stratified medicine and precision medicine. Precision medicine, Prof. Tariq stated is not easy but it is coming up fast. He then referred to the use of precision medicine in complex diseases. Telemedicine is also becoming very popular. He also talked about healthcare simulation, pain management by changing patient perception. Electronic Health Record has made things quite easy. Some healthcare facilities are using it partially while others are using it fully. By next year Aga Khan University Hospital will achieve 100% EHR. He also discussed clinical learning innovation, its effects on teaching and training. In this the problem is that students spend less time at bedside. During Covid19 pandemic virtual bedside teaching rounds of Covid patients were started. Now mixed reality headsets are being used to reduce the need for PPEs. He also talked about virtual ward rounds and clinical clerkships. He concluded his presentation by stating that innovations and medicine should go together. Medical Technology will transform healthcare and these innovations are promising.


Participating in the discussion, Prof. Eice Mohammad remarked that Prof. Tariq has referred to innovations with the use of medical technology but one cannot minimize the importance of human touch, human values which is lacking with the use of technology. Clinical skills are extremely important and without proper history taking and physical examination, talking and listening to the patient, one cannot do justice and practice ethical medicine.

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