Diagnosis of epilepsy is clinical for which an eye witness account is important - Mohsin Nazeer


Neurological Diseases, Diabetes, Endocrine sessions during PSIM Conference
Diagnosis of epilepsy is clinical for which an
eye witness account is important - Mohsin Nazeer
Timely taken Paracetamol is good enough in Migraine
management - Ahsan Nauman

Lahore: Prof. Naeem Kasuri along with Prof. Ahsan Nauman chaired this session devoted to Neurological Diseases during PSIM Conference held here on March 14th 2020. Dr. Mohsin Nazeer was the first speaker who gave an overview of Epilepsy. Its cause, he said, could be tumors, brain haemorrhage and certain drugs can also cause seizures. At least two unprovoked seizures during twenty four hours are essential to label a patient of epilepsy. It could be focal awareness or focal impaired epilepsy. In occipital lobe epilepsy the patients may have hallucinations. Some patient may experience sudden onset and sudden disappearance of seizures. In pseudo seizures there is variability in characteristics of seizures. Tongue bite may be at the end.

Continuing Dr. Mohsin Nazeer said that diagnosis of epilepsy is clinical for which an eye witness account is important. EEG is just confirmatory. Doctors who cannot take history and patients who cannot give proper history are likely to give and get bad treatment. Looking at Video recording during seizures is important. EEG should only be done if there is possibility of epilepsy. Neuro imaging should not be asked for routinely. During seizures try to turn the patient to one side. Choice of Anti Epilepsy Drugs depends on the type of seizures. His advice to the treating physicians was to simplify the treatment with monotherapy and add another drug only if it is needed. Non pharmacological treatment includes surgery and palliative care. About 52% of patients remain seizure free up to five years after surgery. Use of folic acid is beneficial and one should avoid teratogenic drugs. He concluded his presentation by restating that diagnosis of epilepsy is clinical. EEG is only an aid to confirm diagnosis.

Prof. Naeem Aslam alongwith Prof. Khalid Abaidullah chairing a scientific session
during the PSIM Conference held at Lahore recently.

Dr. Athar Iqbal discussed management of hyper acute stroke and use of thrombolytic therapy. He described in detail the protocol for use of tPA and management pitfalls. He then referred to the non-availability of tPA, its cost, lack of trained personnel, patient’s signs and symptoms suggestive of stroke. It is important to know when the patient was seen normal last time, hence get good history, Glasgow Coma Scale more than eight means a definite onset of stroke. He also referred to the NIH scale of Stroke. High blood pressure of 185 (SBP) is a contra indication for tPA. If the onset is now known, take the patient to MRI, if there is no blood clot; it means stroke occurred just three to four hours earlier. He also disclosed that soon a six bed stroke unit will be established in their Ward.

Prof. Ahsan Nauman gave an overview of Headache, Migraine and Cluster headache. Young female patients, he said, are symptom free during interval of attack of migraine. Ask the patient has it affected their work, had nausea and does the light bother them. Migraine will not allow patients to work. Counseling is more important. The physicians must listen to the patients, explain the risk, side effects of drugs to the patients, and ask them to keep a diary of severity and duration of attack. Identify the triggers. Use of mobile can also trigger migraine attacks. Over eating, no breakfast, smoking, high altitude, drugs, anger, anxiety, depression, fear are some of the trigger factors. Patient will rest in darkness and quiet room. Timely taken Paracetamol is good enough. NSAIDs and Triptans are also helpful and improve quality of life. Prophylaxis reduces the frequency and severity. TCAs, Valporate, Pziotogen are safe and can be used. He also referred to effects of chronic migraine and advised life style changes.

Cluster headache is unilateral, on one side and it is always severe, never moderate. It lasts from 15-180 minutes. In acute attack, no oral drug is effective. Verapamil and lithium carbonate can be helpful. Tension Type Headaches lasts for minutes to weeks. In some patients it may last from thirty minutes to seven days. NSAIDs and Muscle relaxants are quite helpful. Overuse of medications can also result in headache. He also talked about complicated vascular headache. He concluded his presentation by stating that we must Thank Allah Almighty for whatever we have got and share our happiness with others.

Prof. Naeem Kasuri in his concluding remarks said that for diagnosis of epilepsy eye witness account is very important. Ask the patient’s attendants, relatives to make a video on mobile when the patient has a seizure. It will help in determining the nature of seizures. For management of stroke, tPA is very useful but unfortunately it is not easily available and it is also very expensive. Migraine and Tension Type Headache are two different types. Some patients always have two headaches. Cardiac arrest can also lead to fits.

Diabetes and Endocrine Session

Prof. Bikharam Devrajani along with Prof. Ali Jawa and Dr. Atif Munir chaired this session. Dr. Zahid Miyan from BIDE Karachi was the first speaker who highlighted the safety and efficacy of SGLT2 Inhibitors in diabetes. He pointed out that people suffering from diabetes are increasing and it is the main cause of Cardiovascualr problems. The problem starts much earlier than when one knows about the presence of diabetes. Similarly Heart Failure patients do not know that they are also suffering from diabetes. Diabetes and CKD both present increased risk of cardiovascular disease. It is estimated that during the last twenty four hours, fourteen thousand four hundred patients might have died worldwide due to diabetic foot but it does not make any news. Diabetes and hypertension are here and these diseases won’t go away. Any new drug for the treatment of diabetes has got to be cardio protective, safe in cardiovascular disease.

He then shared the highlights from the EMPA trial which enrolled 7020 patients which showed reduction in mortality from any cause. There was significant reduction in mortality with the use of SGLT2 Inhibitors after few months. There was reduction in heart failure, 35% reduction in hospitalization of patients, reduction in worsening of the kidney disease, 55% reduction in renal replant therapy. He emphasized that the treatment has to be patient centered, individualize patient treatment and look at the HbA1c. GLP1 and SGLT2 Inhibitors are safe and effective. One can start treatment with SGLT2 Inhibitors if the patient is already taking GLP1 or one can add SGLT2 Inhibitors. It shows efficacy in just three months time. He then described the fuel hypothesis in detail and shared the cardio renal benefits related to EMPA. He suggested step wise approach to prescription of SGLT2 Inhibitors. One can start with SGLT2 Inhibitors and add on Metformin but one must discuss the possible side effects of these drugs with the patients, he remarked.

Dr. Abbas Raza gave details of the DIARAMDAN- a real world evidence in patients with Type2 diabetes mellitus treated with Gliclazide MR during fasting. He pointed out that while managing diabetes, all cause mortality and cardiovascular safety are some of the issues. He highlighted the importance of safe and smart use of sulphonylureas. Hypoglycaemia is a major problem but the most important question about sulphonylureas was is it always a problem with the use of sulphonylureas? There is a difference in hypoglycaemia which is different with different drugs. Continuing Dr. Abbas Raza said that some people with diabetes can fast while others cannot fast. The DIA-RAMADAN study showed that 60% of the people fasting were 90% of the time fine. We know people with diabetes fast but we wanted to see its effects on hypoglycaemia risk. Did it affect the same Hypo in patients taking Gliclazide. Patients with liver failure and kidney failure were excluded. We started treating patients before Ramadan to see how many develop Hypo and how many develop severe Hypo episodes. We also wanted to see its effect on weight. The trial included 640 patients of which 240 were from Pakistan. Duration of diabetes was six years and their mean HbA1c was 7.5. The patients were divided into three groups, the first got Gliclazide MR alone, others got Gliclazide MR plus one oral anti diabetic drug and the third group got Gliclazide plus two oral anti diabetic medications. The patients who were put on Metformin also developed Hypoglycaemia during Ramadan and it is always high during Ramadan. In this study none of the patients who just got Gliclazide MR suffered from hypoglycaemia and required intervention. In the second group there was no effect before the start of the study. The patients got better as regards HbA1c and their fasting blood glucose also reduced.

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