TB dots strategy in District Rawalpindi: results and lessons.

BACKGROUND: Tuberculosis (TB) is one of the most ancient diseases of mankind. Despite newer modalities for diagnosis and treatment, unfortunately, people are still suffering, and TB is among the top 10 killer infectious diseases in the world. TB is a devastating disease due to its rapid transmission and high rate of mortality causing around 1.8 million deaths annually. This study was conducted to evaluate the effectiveness of the Directly Observed Therapy Short-course (DOTS) in the target population. METHODS: Two Tehsils of District Rawalpindi were selected for the study. All patients under TB treatment attending Basic Health Units (BHUs) and Rural Health Centres (RHCs) were included in the study. The patients with extra pulmonary TB and children under five years of age were excluded from the study. All patients were contacted individually and asked about the DOTS program activity using a preformed questionnaire that mainly contained questions regarding knowledge of the patients about their disease and the role of health facility in treating and following the disease. RESULTS: Out of the 224 patients who were included in the study, 87 (38.8%) were male, and 137 (61.2%) were female. Majority (48.8%) of the patients was in age group of 21-40 years and 62.5% patients had positive family history of TB. Among the patients, 51.8% were illiterate, 31.7% had studied till primary level, and only 16.5% had the educational qualification of Matric or above. In our study 69.2% of patients themselves or through their relatives reported to the health facilities to get treatment, while the rest were picked by community health workers, 62.9% were diagnosed by the public hospitals, 23.2% were diagnosed by general practitioners and 12.9% by the federal public hospitals. In our study 69.6% of the patients were not observed at all or were observed by the family members. CONCLUSION: TB is mainly a disease of the poor and illiterate people. Despite many achievements a bulk of patients are not picked by the community health providers nor are they properly observed. We need to improve the current working of the DOTS personnel. General practitioners are playing a big role in diagnosing the disease, so they need to be integrated in the DOTS to effectively diagnose and control TB.

Perceptions of cadaveric dissection in anatomy teaching.

BACKGROUND: Anatomy professors world over are lamenting about medical students' lack of interest in dissections and its diminishing utilisation in medical studies. The objective of our study was to find out the reasons why some of the Pakistani medical students were avoiding dissections. METHOD: We conducted this study in 5 medical colleges of Pakistan from Dec 2010-Oct 2011. Questionnaires were prepared and administered to more than 500 Pakistani medical students, at least 6 months after their first cadaver dissecting session. Mostly 1st and 2nd year medical students participated in this study. RESULT: Around 43% students have actually performed dissections in some form, whereas around 57% had never touched the cadaver. Further evaluation of these results revealed that out of 57% of students, 45% avoided dissection due to bad smell of formaldehyde, 37% due to moral/ethical grounds, 22% due to low motivation and respect of human body, 19.4% due to anxiety, 18.6% due to religious reason, 16% due to fear, asthma and emotional reaction, 9.4% due to toxic chemical, 8.6% due to laziness and 7% due to nightmares. CONCLUSION: In spite of availability of required number of cadavers in all 5 medical colleges and a clear realisation amongst the students that dissecting cadaver is an effective way of learning anatomy; majority of students were not very keen and had therefore not performed dissection even once.

Hypocholesterolemia secondary to atrovastatin therapy.

After the advent of Statins in 1960's, they are being extensively used as Antiathrogenic drug for Primary Hyperlipidemia, Angina, Ischemic Heart Disease (Medical or Post Surgical), Atherosclerosis, Diabetes mellitus and Hypertension. Rarely, these drugs have been observed to cause hypocholesterolemia. We present a case of forty years old male who was started on Atorvastatin after his angioplasty following anterior myocardial infarction. Six weeks after the start of antilipid drug patient developed symptoms of phobias, nightmares, insomnia, forgetfulness, body aches, muscle cramps, cognitive, sexual and psychomotor disturbances. On investigation he was found to have hypocholesterolemia. Atorvastatin was stopped and dietary restrictrictions were lifted. Over five month patients symptoms resolved as the serum cholesterol levels became normal. Because of similarities of symptoms of hypocholesterolemia secondary to antilipid therapy and the disease itself, hypocholesterolemia was overlooked initially by physicians. Patients on antilipids must be evaluated for any fall in serum cholerterol if they develop unusual symptoms and patients on long-term antilipids must have regularly lipid profile checked.

Comparative therapeutic response to pegylated interferon plus ribavirin versus interferon alpha-2b in chronic hepatitis C patients.

BACKGROUND: Hepatitis C is an epidemic worldwide since discovery in 1989. Conventional interferon alpha-2b plus Ribavirin therapy was started in 1998 but over all sustained viral response (SVR) rates are much below the desired rates to eradicate the diseases and stopping its epidemic. This study was conducted to access the therapeutic and cost-effectiveness of long acting pegylated interferon alpha-2b plus Ribavirin therapy verses conventional interferon alpha-2b plus Ribavirin. METHODS: This comparative study was done at PAF Hospital Shorkot Cantt from July 2005 to July 2008. One hundred anti-HCV positive patients were selected randomly for the study according to willingness due to cost affordability of the patients for conventional interferon. Group-A was labelled as pegylated interferon alpha-2b plus Ribavirin group, and Group-B interferon alpha-2b plus Ribavirin group. Both groups were given treatment for 24 weeks. Early virological response (EVR) was accessed at 12 weeks of treatment. Sustained virological response (SVR) in both the groups was done at 24th week during the treatment and 6 monthly after treatment for 2 years. Initially non-responders and relapsed patients within 2 years of treatment were re-treated for 24 weeks with the same treatment. In both groups nonresponders and relapsed patients were labelled as resistant patients. Both groups were followed with same protocol for 2 years. RESULTS: Out of 100 patients included in the study, 34% were females and 66% were males. Group-A patients over all showed 94% SVR as compare to 80% in Group-B in 2 year follow-up. Group-A showed 6% resistant patients as compare to Group-B (20%). Conventional interferons were better tolerated. Higher incidence of side-effects was seen in Group-A. CONCLUSION: Pegylated interferon plus Ribavirin showed 94% SVR in 2 years. Pegylated interferon plus Ribavirin is the treatment of choice.

Comparative effectiveness and adverse effects of interferon alpha-2b plus ribavirin therapy in hepatitis 'C' for 26 weeks.

BACKGROUND: Hepatitis C is major emerging challenge for pathologists and treating physicians all over the world. Already 10 million Pakistani population has become anti-HCV positive. It is not only affecting hepatobiliary system but with passage of time research is revealing that Hepatitis C is going to involve almost every organ of the body. With timely diagnosis and treatment, millions of patients can be saved from morbidity and mortality. The nation has to sacrifice initial economic allocations to avoid later millions of mortalities and greater economic losses on affected patients and to support their families. The objective of this study was to evaluate effectiveness of combine therapy of Hepatitis C in local population of Pakistan. METHODS: This case series study was done at CMH Okara, Kohat, Abbottabad, and PAF Hospital, Shorkot from August 2000 to August 2009. All 1,000 patients from 10 to 60 years of age, confirmed anti-HCV Positive by ELISA and PCR Positive for HCV RNA, were subjected to Interferon alpha-2b and Ribavirin therapy for similar period of time. Response and adverse affects were observed by clinical examination, blood complete picture including platelet count and ALT fortnightly. PCR for HCV RNA and ultrasound abdomen (hepatobilliary system) was done quarterly during treatment and 6 monthly for 2 years after treatment to review the sustained response and relapse. RESULTS: Over all cure rate after 2 years was 855 (85.5%) excluding the 50 (5%) of initial resistant to one year treatment and 95 (9.5%) re-treated relapse cases. One hundred and forty-five (14.5%) patients were found to be resistant to treatment. CONCLUSION: Hepatitis C must be treated timely after proper diagnosis. Interferon and Ribavirin combination have shown high 'cure' rate in Hepatitis C. In spite of high cure rate of 85.5% with timely and proper treatment, low socio-economic status is a major problem for poor individuals to get treatment. Preventive aspect must be strictly followed and implemented.