800 patients’ visit PIC daily & about ten primary angioplasties are performed every day-Bilal Mohydin


Clinical proceedings of PSIM Mid-Summer meeting
800 patients’ visit PIC daily & about ten
primary angioplasties are performed
every day-Bilal Mohydin
Hair dye poisoning is life threatening & so
far it has been overlooked-Munir Azhar

SWAT: The first scientific session during the Pakistan Society of Internal Medicine Mid-Summer meeting held at Swat was devoted to Acute Care Medicine. It was jointly chaired by Prof. Sajid Abaidullah, Prof. Aziz Ahmad, Prof. Bilal Bin Younas and Prof. Bacha Amin while Dr. Madeeha was the moderator.

Dr. Bilal S.Mohydin from Punjab Institute of Cardiology was the first speaker who talked about Acute Coronary Syndrome. He urged the physician collegues to not only manage it but do something more for the patient. It is important to have more robust heart at our disposal. He suggested quick analysis ECG, if need be do primary PCI or go for thrombolysis and manage the patient. If ECG is abnormal send the patient for PCI, the ambulance for transfer of the patient should be better equipped. Giving details of the PCI data, he said, 5-10% of patients are Stemi who come with chest pain. Another 15-20% is non-Stemi, unstable angina account for 10%. About eight hundred patients visit Punjab Institute of Cardiology daily out of which about ten patients undergo primary angioplasty every day. It is important to talk to the family as soon as you get the patient. Almost seven hundred patients out of the 800 who visit the OPD daily are non-cardiac. In order to ensure rapid turnover, early discharge is practiced and patient is managed at home.

Some patients come with history of chest pain, some complain of chest discomfort while some may come with full blown pain. There is persistent ST segment elevation. ECG shows myocardial infarction. Rush these patients to the Cath Lab. If the patient cannot be shifted, do thrombolysis. Give two tablets of Dispirin immediately. If there is no ECG, look at cardiac markers. He also talked about atherosclerosis after Myocardial Infarction and imbalance between demand and supply. PCI must be performed within one hundred twenty minutes. Those patients who look very sick are very dangerous. In case more than one vessel is involved, do it at the same time. Speaking about Non-Stemi patients, Dr. Bilal Mohydin said that they may have pain but no abnormal ECG. These patients usually present late in the OPD. They can be put on 2B3A, dual antiplatelet therapy and beta blockers. Manage these patients with drug therapy. Cardiac patients should be shifted in an ambulance which is properly equipped, has trained staff to do CPR. Some patients may be suffering from multi organ failure. Mobile ventilator and Ambu bag should be available in the ambulance. During post care these patients should be advised to walk, improve their diet and must be followed up on regular basis. In case of re-event, be more aggressive, prevent the preventable. Sit with the patient, let the family know and give them all the details. He concluded his presentation by saying that excellence should be your pathway and not destination and acute coronary syndrome can hit any one anytime.

Kala Pathar Poisoning

Prof. Munir Azhar from Quaid-e-Azam Medical College Bahawalpur discussed Kala Pathar Poisoning. He pointed out that this hair dye is cheap and easily available and accessible. There is no antidote available. We see many such cases very week. Now when PPD free hair dyes are available, these dangerous hair dyes should be banned. During 2017 they had 2261 cases of poisoning which included 1243 of PPD. In the year 2018, the number of cases reduced to 2029 and PPD cases accounted for 968. Anaphylaxis is life threatening. It can be detected in blood. Intramuscular Adrenaline injection should be administered and tracheastomy should be performed immediately. Maintain airway, secure breathing and ensure circulation. Do gastric lavage and go for forced dieresis. He then discussed in detail the management protocol for these patients. Consult Nephrologist and ensure cardiac support. He emphasized the importance of timely diagnosis of these cases and putting ban on the availability of this hair dye. We also need to educate the community so that this innocent looking powder does not kill people. Social aspects should also be looked into. He concluded his presentation by stating that hair dye poisoning is life threatening and so far it has been overlooked.

Photographed during the PSIM Mid-Summer meeting held at Swat
from (L to R) are Prof. Tariq Waseem Prof. Javed Akram, Prof. Israr
ul Haque and Prof. Aziz.

During the discussion Prof. Javed Akram suggested that Prof. Munir Azhar should prepare the PC-1 Form and we should try to find out its antidote for Kala Pathar poisoning. UHS and PSIM will support this project. Cath Lab, he further stated, should be properly equipped and every one coming to PIC with MI should be offered primary PCI. Dr. Bilal Mohydin remarked that primary PCI is available in the morning and this facility cannot be made available at all other cardiac centers since no cardiac surgery back up is available.

Challenges and
Updates in Infection

This session was jointly chaired by Prof. Javed Akram and Prof. Akmal Bhatti. Prof. Aziz from Swat Medical College talked about the Dengue Fever epidemic in Swat in 2013. He pointed out that about fifty million dengue fever infections are reported annually. High number of deaths was reported in 2008. In the 2013 epidemic, first case was reported on 14th of August and last case on 20th November. The total number of cases included 59,036 of which 9038 were confirmed cases. Five thousand one hundred ninety were admitted of which thirty seven died. In those days all wards were full of dengue patients. We had an 80-bed Dengue ward. We established a 25-bed High Dependency Unit. We also organized training workshops. Laboratory capacity was also improved while the hospital was also provided hematology analyzer. About 68% patients were male and 32% female. We did learn some lessons from this epidemic. He then highlighted the importance of clinical audit, preventive strategy and curative services. Epidemic sensitive areas were identified. We also mobilized the surveillance teams, he added.

Dr. Somia Iqtidar from KEMU was the next speaker who also talked about dengue fever. She pointed out that it accounts for 70-500 million cases annually while twenty five thousand deaths are attributed to dengue fever annually. She then gave details of dengue fever which was identified for the first time in various cities of Pakistan like Karachi, Hub city and then gave details of 2011 epidemic in Punjab. In 2019 all districts of Punjab are reporting Dengue cases. Over twenty two thousand laboratory tests have been performed and so far 325 patients have died. We prepared the Dengue GCP Guidelines. It is now possible to identify suspected, probable and confirmed cases of dengue. She discussed the signs and symptoms of dengue in detail and said that now all these dengue cases are reported. She then referred to dengue hemorrhagic fever, dengue shock syndrome and DHF Class I-IV. There is a febrile phase, those in critical phase should be admitted in hospitals and then comes the recovery convalescent phase. She suggested managing these patients in hospital in High Dependency Units and then discussed their management in detail. Systemic treatment will reduce the fever. Advise patients to take soft diet and warning signs should be told to the patients. Patients suffering from DHF will say that they are not feeling well. They may complain of abdominal pain, decrease in urine output. These patients should be admitted. Control fever. Dengue shock is the most critical phase. Manage shock but do not overlook the fluids. Balance it out.

Picture from (L to R) shows Prof. Javed Akram alongwith Prof. Tariq Waseem presenting
memento to Prof. Sajid Abaidullah, Prof. Aziz while the next picture shows Prof. Aziz
memento to Prof. Munir Azhar and Dr. Bilal S. Mohydin during the PSIM
Mid-Summer conference held at Swat from August 29th to September 1st 2019.

Continuing Dr. Somia Iqtidar said that is it important to know how much fluids should be used, how many times and at what rate and which fluids? Try to replace the fluids in four to eight hours. In case of emergency one might have to rush the fluids. In some cases, replace the fluids in twenty four hours. Fluids replacement rate also depends on the patient’s condition. One can use colloids or crystalloids fluids. Normal saline can be followed by crystalloids. It is important to recognize the critical phase early and predict leak. Match the rate of fluids and leak. She laid emphasis on correct fluids therapy, aggressive monitoring and documentation.

Drug Resistant Typhoid Fever

Prof. Zafar Iqbal Chaudhry talked about management of extensive drug resistant typhoid fever. He stressed the importance of quick accurate diagnosis, selection of appropriate antibiotic, death and management of carriers he said were some of the problems that we face related to typhoid fever. He emphasized that Typhidot test has no place in its diagnosis. One should always opt for blood culture. Any fever which lasts for more than five days, one should suspect typhoid. Rising trend in fever should be suspected of typhoid. S. Typhi is isolated in blood and on bone marrow culture. Serological tests have no place in diagnosis. Now we see lot of MDR cases. They are resistant to all available antibiotics. In such cases it is advisable to start treatment with carbapenams followed by AZT. Haemorrhagic fever, sever sepsis, septic shock patients should be managed in tertiary care hospitals. These patients may also present with jaundice, drowsiness, abdominal pain and intestinal haemorrhage. In case of complicated cases of typhoid fever, do blood test before starting antibiotic therapy. Do not try Typhidot or Widal test. Start treatment with cephalosporin’s which are now considered the first line drugs for its management. After blood culture, change the antibiotic accordingly. It takes five to seven days to improve the patient. Do not rush to change the antibiotic as fever will come down gradually. If appetite improves, it is a sign of improvement. Monitor the complications. Usually treat with just one drug. If not treated early, it will increase chances of relapse and complications. Never use AZT as an empirical drug but it should be reserved for resistant cases. Complete the treatment for two weeks.

HIV epidemic in Pakistan

Dr. Muhammad Zaman Khan from Allama Iqbal Medical College made a presentation on HIV epidemic and asked are we in Pakistan ready for this? In 2012 there were 75 million replication and 36 million deaths were attributed to HIV. According to reports 36 million people live with HIV infection of which 34 million are adults. Most of the cases are in Sub Saharan Africa and 3.9 million cases are in Asia. We in Paksitan, Dr. Zaman opined, are not protected from HIV epidemic. While worldwide the prevalence of HIV is decreasing, in Pakistan it is increasing. This disease, he reiterated, is not curable but treatable. According to reports there are nineteen thousand new cases which are identified in Pakistan annually. Only 7% of them are on therapy though 100% of them should be on treatment. The highest prevalence of HIV is in Injection Drug Users where it accounts for 38.4%. Female sex workers have the lowest cases as they are more aware of its risk factors. Female sex workers are also focused for education programmes. Male Sex Workers have the highest prevalence. For treatment three drug combinations is most effective. Single pill is now also available for the treatment of AIDS. If treatment is started early the survival is better. He stressed the importance of treat to targets. He then gave details of 162 patients out of which 66 patients were virally suppressed. IDU patients, he stated, are the most difficult population to treat.