We need to ensure judicious use of resources and work for affordable healthcare-Maj.Gen. Salman Ali


 Proceedings of FAMILYCON 2017 held at Islamabad

We need to ensure judicious use of resources and
work for affordable healthcare - Maj.Gen. Salman Ali

PCOS is a clinical diagnosis, it has no treatment and one
can just improve symptoms - Prof. Rizwan Chaudhry

ISLAMABAD: Maj. Gen. Salman Ali Senior Vice President CPSP was the chief guest in the inaugural session of FAMILYCON 2017 organized by Pakistan Associate of Family Physicians here on August 13, 2017. In his address Gen. Salman Ali remarked that family physicians are the backbone of primary healthcare.  We need to work for affordable healthcare in Pakistan. We also need to ensure judicious use of resources. We in Pakistan has seen almost all the civilizations. Reading alone is not enough, we need to do some research. Once we become Sahib-e-Kitab, we will move forward. He concluded his address by stating that: “Khushi Ka Nashiman Teray Dil Mainn Hai”.

President of Pakistan Association of Family Physicians Dr. Aftab tracing the history of PAFP said that it was late Dr. Bashir A. Malik who started this CME activity about thirty seven years ago. Health and Education remain neglected in Pakistan. We still have tuberculosis, high maternal mortality and child mortality, malaria and typhoid. We need good primary healthcare to tackle these diseases. His address was as usual supplemented with lot of poetry of Allama Iqbal. Dr. Ashfaq Rana presented the Secretary’s report. Dr. Altaf Cheema also spoke on this occasion.

Scientific Sessions

The first session was devoted to Women’s Health. Brig. Mamoona Mushtaq was the first speaker. Her presentation was on Role of HCG in Pre-term Labour. She first described the recent advances in pre-term labour. Its incidence, she said was about 20% in developing countries as compared to 7-12% in the developed world. Globally about 12.9% of births are pre term. She also pointed out that almost 85% of deaths at Military Hospital Rawalpindi in the Dept. of Obstetrics & Gynaecology were due to premature labour. Very low birth babies can be saved at the Neonatal Intensive Care Unit. Risk factors for pre term labour include low socio economic status, multiple gestations, cervical insufficiency, prior pre-term labour, uterine anomaly and maternal infections.

She suggested treatment of infections to prevent pre-term labour. Good history and physical examination are important for diagnosis. She also  suggested triage at arrival, use of steroids and fetal monitoring. Ultrasound can be helpful. Use of uterine relaxants like indomethacin and Nifidipine are also quite useful. Contra indications include asthmatics, cyst, cancer, pain, irritability and allergic reactions.

This was followed by an excellent presentation by Prof. Rizwana Chaudhry from Rawalpindi Medical University who talked about Polycystic Ovarian Syndrome (PCOS). In this condition, counseling and understanding, she opined,  is very important. PCOS is very common and later on these patients become diabetic and suffer from metabolic syndrome. Endocrine disorders are quite common in developing countries. A study done in UK among Asians showed its prevalence of 52%. Speaking about triggering signals she mentioned family history of diabetes mellitus, acne, hirsuitism, ultrasound cyst, irregular cysts is also one of the causes of PCOS. Some patients may have a life style which increases its prevalence, some have inherited risk factors. They increase insulin resistance, result in alopecia, acne and its diagnosis is the main problem. These patients suffer from depression, sleep apnea, low quality of life. PCOS does not need lot of investigations as diagnosis is just clinical. It has no treatment and one can just improve the symptoms. Counselling is very important in PCOS. Patients should be advised exercise and weight reduction. Those complaining of continuous bleeding will need treatment but if there is no bleeding, there is no need for treatment. Patients can be investigated for sub-fertility. They should be advised to get their Blood Pressure and Diabetes checked every year and manage them properly. PCOS management is just management of symptoms, she remarked. Responding to questions during the discussion it was stated Metformin has a role in PCOS and it has to be continued. Bariatric surgery also has a role in some patients. Prevention of childhood obesity is important.

Prof. Nasira Tasnim from PIMS talked about Fistulae. She pointed out that during 2006, a six bed fistulae center was established which consisted of fistulae room. These patients remain isolated, it has social implications. Obstructed labour is the main cause of fistula. Other causes are malnutrition, early marriage. C-sections in time can prevent fistula. She laid stress on education of the population, improvement of socio economic conditions. In case of difficult labour, the patients should be referred to other centers early where they can be managed properly. She also discussed principles of bladder injury repair and opined that one should not panic as it is repairable. Management of Vesico Vaginal Fistula was also discussed.

Brig. Shehla Baqai said that maternal mortality and morbidity is an indicator of country’s health services. Maternal health, she opined, is a public health issue and human right concern. Nations thrives when mothers survive. She advised following the human right based approach to maternal mortality.

Dr. Uzma Ali discussed atopic dermatitis.  She also talked about acute eczema, sub acute and chronic eczema. In shoe dermatitis the skin thickens. Treatment is with antihistamines, topical steroids. One should treat the secondary infections, use of immunomodulators is quite helpful. Use ointment on dry skin and lotions on less dry skin. One should use histamines which have a sedating effect. Steroids should be used carefully particularly on the face. Local burning and pruritus are some of the side effects of topical steroids.

Dr. Farida Waqar who was chairing the session in her concluding remarks commended the presenters and re-emphasized the importance of counselling in PCOS which has no cure and one can only treat the symptoms.

In the next session Dr.Arshad Malik talked about trigeminal neuralgia. It could be idiopathic or due to jaw bone cavities or cranial trauma. History and physical examination are important for diagnosis.

Maj.Gen. Salman Ali Principal Fazaia Medical College discussed GI Bleeding in children. He pointed out that the family physicians see more children than pediatricians, hence they must know how to manage such cases. GI bleeding should be suspected in case of Melena, rectal bleeding. One should classify upper or lower GI bleeding. Find out the present illness, take good history and family history of any systemic symptoms, do proper physical examination. Iron intake and certain food items can also result in gut bleeding. He then discussed indications for endoscopy, differential diagnosis and mentioned about stress ulcers, anal fissures, polyps.  He also discussed endoscopic interventions, inflammatory bowel disease, ulcerative colitis and rectal prolapse.

Afternoon Session

Dr. Naeem Malik from PIMS was the next speaker who talked about Medical Uses of Aspirin. He pointed out that it was the most economically priced antiplatelet agent which is life saving in AMI, it is useful in CAD, ACS, Primary and Secondary prevention of CAD, TIAs, Stroke, Hypertension, Diabetes Mellitus besides prophylaxis  against DVT and Pulmonary embolism. In acute chest pain, one should immediately take soluble aspirin 320mg or chew it if it is enteric coated aspirin. It has 21% mortality reduction in AMI, one has to continue taking low dose aspirin therapy if there are no contra indications. In ACS continue low dose aspirin therapy. Patients having cardiac intervention procedures like angioplasty and stenting will also require low dose aspirin therapy for indefinite period.

Continuing Dr. Naeem Malik said that now some new antiplatelet have come to the market. Combination of clopidogrel and aspirin is better than monotherapy with aspirin. In patients who have implants of DES, they should take clopidogrel and aspirin for one year and then stop clopidogrel and continue with low dose aspirin therapy. CABG patients also need to continue aspirin therapy for life long. In case of acute stroke or TIA the recommended dose of Aspirin is 300mg for few months and then continue with 150mg daily. Generally people over the age of forty years in Paksitan with one or two risk factors should be put on low dose aspirin therapy. Studies have shown that patients who were taking Aspirin, had 33% less myocardial infarctions which is a very impressive figure. In DVT Aspirin therapy prevents patient’s long stay in bed and there is almost 43% reduction in pulmonary embolism. Studies have also showed over 50% reduction in DVT which is again a very encouraging figure. Emerging indications for Aspirin therapy include colorectal cancer, esophageal, gastric cancer. He also mentioned about absolute and relative contraindications to Aspirin therapy like hypersensitivity to Aspirin, bleeding diathesis, active peptic ulcer and pregnant women after 36 weeks of pregnancy. Responding to a question Mr.Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation who was co-chairing this session said that in normal circumstances low dose Aspirin therapy should be preferred at bed time because it will take care of the early morning spike in blood pressure as most of the heart attacks occur early in the morning. Obstetricians and Gynecologists are also using it in patients with bad obstetric history, recurrent abortions and infertility while it has a role in management of pregnancy induced hypertension as well.

Dr. Ghulam Shabbir discussed about vaccinations against communicable diseases and MDG goals, challenges in EPI programme. Prof. Fayaz Ahmad Shah spoke about management of dyslipidaemias. The treatment goal of TGs of 150, he said, was desirable. Dose of statins can be reduced once the cholesterol levels have become stable. Doctors should take care of their health as they are a very high risk community, he added.

Prof. Shahbaz Kureshi in his presentation discussed the usefulness of combination therapy in management of hypertension. He laid emphasis that we should take all possible measures to treat hypertension, control and manage blood pressure to avoid stroke. He also emphasized the importance of life style management. One can check and prevent major heart attacks, strokes if hypertension is identified early and managed appropriately. Usually people are scared of cancer but mortality is high with cardiovascular diseases. Non compliance with drug therapy is a major reason for coronary events. Combination therapy improves compliance hence it also saves from lot of morbidity and other complications. Studies have shown that almost 66% of patients suffering from hypertension need two drugs to control their blood pressure. Increase in dose also increases the side effects, hence it is better to have combination of two or three drugs rather than increasing the dose of one drug. Now Fix Dose Combinations are available to treat hypertension which gives excellent results. He also referred to EXCITE study results. Once we reduce the number of pills, the compliance is improved and it is also cost effective. Salt reduction, regular exercise and blood pressure control will save the patients from serious complications, he added.

Brig. C. M. Anwar who was chairing the session in his concluding remarks said that Aspirin is an excellent life saving drug and it is the duty of every healthcare professional to promote its use. Immunization is also very cost effective as it has eliminated many diseases in various countries. EPI coverage should be improved. Life style changes is most important and as pointed out by Prof. Shahbaz Kureshi combination therapy is not only cost effective but also has less side effects.

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