Pre-Ramadan diabetes risk stratification and patient education.

The fast (Sawm) is one of the religious obligations "Pillars" of Islam. The target audience of pre-Ramadan diabetes risk stratification and pre-education are the healthcare providers (particularly the Primary care physicians), diabetic patients and community members including general public. As per IDF-DAR (International Diabetes Federation & Diabetes and Ramadan International Alliance) guideline, it is advisable that healthcare providers should arrange pre-Ramadan session (appointment) at least 6-8 weeks prior to Ramadan quantify/stratify the patient risk category and educate all the diabetic patients on Ramadan aspects of Diabetes Mellitus. Diabetic patients are classified in to three risk groups (very high risk, moderate risk and low risk) based on specific patient characteristics. The physician should estimate the effect of fast on the patient, whether he will be able to fast or not, and the patient will estimate his ability and endurance to fast. The mode of Pre-Ramadan diabetes patient education could be group sessions or one to one consultation. Patient education should include information on risks, glucose monitoring, nutrition, exercise and medication adjustment. Studies have shown that pre-Ramadan counseling reduces the incidence of hypoglycaemia. Altering the drug dosage, dietary counseling and patient education, together with regular blood glucose monitoring enables the patients to fast without major complications. Patients classified as very high/high risk including T1DM and pregnant women with diabetes need close medical supervision and focused Ramadan-specific education if they insist on fasting. With the correct advice and support from healthcare providers most people with T2DM can fast safely during Ramadan.

Parenteral iron therapy in the treatment of iron deficiency anemia during pregnancy: a randomized controlled trial.

OBJECTIVE: To compare the efficacy and safety profile of total dose infusion of low molecular weight iron dextran with divided doses of intravenous iron sucrose for the treatment of iron deficiency anemia during pregnancy. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad, over a period of two years from January 2008 to December 2009. METHODOLOGY: Pregnant women at gestational age more than 12 weeks with the confirmed diagnosis of Iron Deficiency Anemia (IDA) were divided into two groups. In the group-A, intravenous iron sucrose was given in divided doses while in the group-B, total daily intake of Low Molecular Weight (LMW) of iron dextran was given. Post-infusion Hemoglobin (Hb) was checked at 4 weeks and at the time of delivery for both groups. Paired sample t-test is applied and comparison (in terms of rise in hemoglobin from pre to post) of both groups was not found to be significant. RESULTS: In the group-A (iron sucrose group), mean pre-infusion Hb levels was 9.09 ± 0.83 gm/dl. Mean increase in Hemoglobin (Hb) was 10.75 ± 1.097 gm/dl after 4 weeks of infusion and 11.06 ± 0.866 gm/dl at delivery (p < 0.001). In group-B (iron dextran group) pre-infusion haemoglobin was 8.735 ± 0.956 gm/dl and the mean increase in hemoglobin was 10.613 ± 1.22 gm/dl at 4-week while mean increase of 10.859 ± 1.11 gm/dl at the time of delivery (p < 0.001). CONCLUSION: Both LMW iron dextran, as well as iron sucrose are equally effective in treatment of IDA during pregnancy, however, LMW iron dextran has the advantage of single visit treatment.

Pakistan's health system: performance and prospects after the 18th Constitutional Amendment.

Pakistan has undergone massive changes in its federal structure under the 18th Constitutional Amendment. To gain insights that will inform reform plans, we assessed several aspects of health-systems performance in Pakistan. Some improvements were noted in health-systems performance during the past 65 years but key health indicators lag behind those in peer countries. 78·08% of the population pay out of pocket at the point of health care. The private sector provides three-quarters of the health services, and physicians outnumber nurses and midwives by a ratio of about 2:1. Complex governance challenges and underinvestment in health have hampered progress. With devolution of the health mandate, an opportunity has arisen to reform health. The federal government has constitutional responsibility of health information, interprovincial coordination, global health, and health regulation. All other health responsibilities are a provincial mandate. With appropriate policy, institutional, and legislative action within and outside the health system, the existing challenges could be overcome.

Public health and the undergraduate medical curriculum: are we preparing physicians for the 21st century?

OBJECTIVE: To investigate the adequacy of the undergraduate medical curriculum in Pakistan to address primary healthcare and public health needs of the community at national level. METHODS: The cross-sectional study used standardised pilot-tested instruments from January 12 to July 14, 2010. Stratified purposive sampling technique was employed to include public and private-sector medical colleges in the study. A total of 174 faculty members were interviewed at 11 medical colleges. Data entry and analysis was done using SPSS 17.0. RESULTS: Of the 174 faculty members, 93 (53%) were male. The age of the respondents ranged between 26 and 68 years (Mean: 43 +/- 9 years). Of the participants, 64 (37%) had worked in a primary healthcare facility at some point in their career. Various aspects of maternal, newborn and child health are not covered by the medical curriculum as reported by the faculty members. CONCLUSION: There is disconnection between academia, primary healthcare providers, policymakers and the regulators. The primary healthcare providers have inadequate representation in the curriculum design. There is a need to re-direct financial resources, medical education, and medical practitioners with a focus on addressing the needs of the rural areas.

Misoprostol for term labor induction: a randomized controlled trial.

OBJECTIVES: The aim of this study was to compare the efficacy of vaginal misoprostol with vaginal dinoprostone for term labor induction. MATERIAL AND METHODS: It was a randomized controlled trial done in the Obstetrics Department, Shifa Community Health Centre, Shifa International Hospital (Teaching Hospital of Shifa College of Medicine, Islamabad). All pregnant women at term pregnancy coming for induction of labor were enrolled. 246 women fulfilled the inclusion criteria. Out of them 208 women consented to be part of the study. These women were then randomized to receive either Treatment A (vaginal misoprostol) or Treatment B (vaginal dinoprostone). Data were completed for 200 women. These included induction labor and induction-delivery interval, fetal and maternal complications, and baby apgar score. RESULTS: Out of 200 women in the study, 100 were in Group A and 100 in Group B. Labor commenced in a mean of 6.67 hours (± 3.63) in Group A whereas it took a mean of 8.41 hours (± 5.13) in Group B (p=0.00). Actual induction to delivery (of the baby) interval was a mean of 11.68 hours (± 4.55) for misoprostol and 15.37 hours (± 5.30) for dinoprostone group (p=0.00). There were no cases of uterine rupture in both groups; however, there were 10 cases of uterine hyperstimulation in Group A and 4 in Group B (p=0.09). CONCLUSIONS: It is time to re-evaluate the role of misoprostol for term labor induction. It is an efficacious and cost-effective alternative to the presently licensed treatment.

To determine the probable causes of death in an urban slum community of Pakistan among adults 18 years and above by verbal autopsy.

OBJECTIVE: To identify the probable causes of deaths through verbal autopsy and identify the health problems prevalent in underprivileged and marginalized communities. METHODS: This was a cross-sectional survey conducted at the community of Nurpur Shahan (Urban Slum), Islamabad, Pakistan in January 2010. W.H.O validated questionnaire was used and 300 adults (age > 18 years) were assessed on their knowledge regarding death of their relatives. All data collected was entered into SPSS version 10.0. The data was re-validated and analyzed. RESULTS: Out of the three hundred deaths, 191(63.7%) were male and 109(36%) were female. One hundred and ninety one (63.7%) deaths were due to heart diseases, 69 (23%) due to accidents and 37 (12.3%) due to unknown causes. One hundred and thirty one of the deceased (43.7%) were issued death certificates. CONCLUSION: This study concludes that heart diseases are the most common cause of death in the urban slum community followed by accidents. A significant proportion of the deaths went unreported which suggests the need of record keeping of such deaths to enrich epidemiological purposes and health and safety interventions in such communities. Ways and means have to be searched to cater to the cardiac health care needs of the underprivileged and marginalized segments of the society.

Predictors of depression in patients presenting with dyspeptic symptoms in a GI clinic.

BACKGROUND: The association between dyspepsia, H. pylori and psychological distress has remained a topic of intense debate over the past several decades. In Pakistan, where depression is highly prevalent and dyspepsia is possibly present in a high percentage of population, little data exist about these common health problems. This study was conducted to determine the frequency and predictors of depression among patients presenting with dyspeptic symptoms in the Gastrointestinal (GI) Clinic of a tertiary care hospital in Pakistan. METHODS: Two hundred and sixty-nine consecutive patients were enrolled in the study based on their presenting symptoms in the GI clinic at Shifa International Hospital, Islamabad. Subjects with prior history of peptic ulcer disease (PUD), gallstones and HCV infections were excluded from the study. Demographic and socioeconomic variables as well as dyspeptic symptoms and important causes of dyspeptic symptoms were recorded. Depression was analysed based on the Urdu version of Beck's Depression Inventory-II (BDI-II). The data were analysed using SPSS-10 for univariate and multivariate analyses. RESULTS: Mild depression was associated with lower education status (p < 0.001), lesser income (p < 0.018), and lower socioeconomic status (0 < 0.009) as well as rural residence (p < 0.026). Smoking, alcohol-use, H. pylori infection, gender and dyspepsia were not found to have any association with depression. On multivariate analysis, education and income group remained significantly associated with mild depression. Clinically significant depression was found to be associated with lower education and rural residence. CONCLUSION: Depression among dyspeptic patients was found to be associated with socioeconomic status rather than dyspeptic symptoms or important risk factors associated with dyspeptic symptoms.

Association of passive smoking with respiratory symptoms and clinical correlates, among married women, in a rural community in Islamabad.

OBJECTIVE: To investigate the association of passive smoking with respiratory symptoms and clinical correlates in married women in a rural area of Pakistan. METHOD: A Cross-sectional study was carried out on married women of Nurpur Shahan (rural Islamabad) by means of an Interviewer administered questionnaire. Systematic sampling of households was done. A total of 296 women were surveyed. The study period extended from January to July 2009. All data was entered and analyzed using SPSS v 10.0. RESULTS: The two major respiratory symptoms that were found to be associated with passive smoking were sinusitis [adjusted O.R(95% CI) 2.2 (1.3 - 3.5), p = 0.001] and cough [adjusted O.R (95% CI) 2.4 (1.2 - 4.8), p = 0.017]. Wood used as fuel for cooking purposes also contributed to one of the symptoms such as headache (p = 0.007). The pulse rate (79 +/- 11 beats/min) of the passive smoking women was statistically significantly higher than the pulse rate (76 +/- 9 beats/min) of the non-passive smoking women (p = 0.012). CONCLUSION: Passive smoking was found to be associated with respiratory symptoms among married women in this study. Higher pulse rate was associated with passive smoking.

Attitudes and perceived barriers of tertiary level health professionals towards incident reporting in Pakistan.

BACKGROUND: A limited framework of incident reporting exists in most of the health care system in Pakistan. This poses a risk to the patient population and therefore there is a need to find the causes behind the lack of such a system in healthcare settings in Pakistan. AIMS: To determine the attitudes and perceived barriers towards incident reporting among tertiary care health professionals in Pakistan MATERIALS AND METHODS: The study was done in Shifa International Hospitals and consisted of a questionnaire given to 217 randomly selected doctors and nurses. Mean ± SD of continuous variables and frequency (percentage %) of categorical variables are presented. Chi square statistical analysis was used to test the significance of association among doctors and nurses with various outcome variables (motivators to report, perceived barriers, preferred person to report and patient's outcome that influence reporting behaviors). P value of <0.05 was considered significant. Student doctors and student nurses were not included in the study. RESULTS: Unlike consultant, registrars, medical officers and nurses (more than 95% are willing to report), only 20% of house officers will report the incident happened through them. Sixty nine percent of doctors and 67% of nurses perceive 'administration sanction' as a common barrier to incident reporting. Sixty percent of doctors and 80% of nurses would prefer reporting to the head of the department. CONCLUSIONS: By giving immunity from administrative sanction, providing prompt feedback and assurance that the incident reporting will be used to make changes in the system, there is considerable willingness of doctors and nurses to take time out of their busy schedules to submit reports.

Investigating the awareness level about diabetes mellitus and associated factors in Tarlai (rural Islamabad).

OBJECTIVES: To determine the baseline level of awareness amongst a rural community about Diabetes Mellitus (irrespective of type 1 or type 2), its risk factors and complications. METHODS: This was a cross-sectional survey conducted at the community of Tarlai, Islamabad, Pakistan, in January of 2008. A structured questionnaire was used and 300 adults (age > or = 18 years) were assessed on their knowledge regarding awareness of Diabetes Mellitus, its risk factors and complications. All data collected was entered into SPSS version 10.0. The data was re-validated and analyzed. RESULTS: Out of the three hundred adults subjected to the survey, only 129 (43%) adults had any awareness of Diabetes Mellitus. Adults with no regular, scheduled exercise were 221 (73.7%) and 256 (85.3%) did not have healthy eating habits. Awareness of risk factors was present in 42 (14%) while awareness of the complications associated with the disease was 65 (22%). Adults which reported as never going for regular checkups to any clinic or hospital were 232 (77%). Family history of diabetes mellitus was statistically significantly associated with awareness about diabetes mellitus (65% vs 32%, p < 0.001), people who were in contact regularly with health care providers were more aware about diabetes and the associated risk factors than those who were not (71% vs 35%, p < 0.001). Sex was not associated (p = 0.28) with awareness about diabetes mellitus, nor was the educational status (p = 0.46). CONCLUSIONS: Majority of adults were unaware of Diabetes Mellitus itself and associated risk factors. Raising public awareness of the disease through outreach programmes and mass media should be planned and implemented.

The structure and function of a new clinical skills and medical informatics laboratory (SCIL) in a developing country--a two year institutional experience.

OBJECTIVE: To combine clinical skills and medical informatics learning by offering a combined 'SCIL' rotation to third year medical students and to determine its long-term impact. METHODS: A combined clinical skills and medical informatics laboratory (SCIL) was set up at our institution with international collaboration. Nine months to one year after formal third year SCIL rotations were conducted, a questionnaire rated on (1-5) Likert Scale was administered to the inaugural class undergoing this rotation. RESULTS: The rotation was rated positively in terms of both acquisition of clinical skills as well as medical informatics skills. (overall rotation rating: 3.32 +/- 0.53) CONCLUSION: Our results have shown the positive long-term impact on undergraduate medical students of a combined clinical skills and medical informatics rotation.

Validity of pipelle endometrial sampling in patients with abnormal uterine bleeding.

BACKGROUND AND OBJECTIVES: We compared endometrial sampling by pipelle endometrial curette with conventional dilatation and curettage (D&C) in patients with abnormal uterine bleeding. METHODS: Endometrial sampling with pipelle curette was performed on 100 patients followed by formal D&C. Samples were labeled as A and B, respectively, and sent to a histopathologist who was blinded as to the method of sampling. The histopathology reports of both samples were compared, taking D&C as the gold standard. RESULTS: An adequate sample was obtained in 98% of cases by pipelle and in 100% of cases by D&C. Pipelle had a sensitivity, specificity, positive predictive value and negative predictive value of 100% for diagnosing endometrial carcinoma, hyperplasia and secretory endometrium. Pipelle also had high diagnostic sensitivity, specificity and negative predictive value (100%, 98% and 100%, respectively) for hyperplasia with atypia, and low sensitivity (57%) and positive predictive value (57%), but high specificity (97%) and negative predictive value (97%) for endometritis. Similarly, for proliferative endometrium, the pipelle technique had values of 94% and 93% for sensitivity and specificity, respectively. Both samples labeled as inadequate for histology by pipelle were polyps on the D&C report. Difficult endotracheal intubation was encountered in two cases of D&C. No other complications of the procedure were observed. CONCLUSION: The pipelle is a safe device for getting an adequate endometrial sample for histology, with a high sensitivity and specificity for detection of hyperplasia and malignancy.