Journal of Services Institute of Medical Sciences
Volume. 07
October - December 2011
PATRON
Prof. Faisal Masud
EDITOR-IN-CHIEF
Prof. Aziz-ur-Rehman
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(Professor of Medicine)
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(Principal SIMS & Professor of Medicine)
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ASSOCIATE EDITORS
Dr. N. Rehan
(Director PMRC (R))
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Prof. Dilawaiz Nadeem
(Orthopaedic Surger y)
Prof. Tahira Tasneem
@
(Haematolog y)
Dr. Anjum Razzaq
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(IPH)
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ASSISTANT EDITORS
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Dr. Muhammad Nasar Sayeed Khan
(Psychiatr y)
Dr. Tayyaba Khawar Butt
(Paediatric Medicine)
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Dr. Muhammad Saeed Anwar
(Patholog y)
Dr. Sajid Nisar
(Medicine)
Dr. Salma Haq
(Patholog y)
Statistician
Muhammad Ghias
Composer & Assistant To Editor -in-Chief
Ameer Ali
No. 04
Editorial Advisory Board
Prof. Dr. Iftikhar Ahmad (Lahore)
Prof. Dr. Mumtaz Hasan (Lahore)
Prof. Dr. Humanyun Maqsood (Lahore)
Prof. Dr. Anwar A. Khan (Lahore)
Prof. Tahir Shafi (Lahore)
Prof. Dr. Bashir Ahmed (Lahore)
Prof. Dr. S.A.R. Gerdezi (Lahore)
Prof. Dr. Shamim Ahmad Khan (Lahore)
Prof. Dr. Wasif Mohayudin (Lahore)
Prof. Dr. Iqbal Butt (Lahore)
Prof. Dr. Rashid Latif Khan (Lahore)
Prof. Dr. Tahir Saeed Haroon (Lahore)
Prof. Dr. Farrukh Khan (Lahore)
Prof. Dr. A. H. Nagi (Lahore)
Prof. Dr. Kartar Dhawani (Karachi)
Prof. Dr. Abdul Malik Achakzai (Quetta)
Prof. Dr. Fareed A. Minhas (Rawalpindi)
Prof. Dr. Zafar Iqbal (Lahore)
Prof. Dr. Alaf Khan (Peshawar)
Prof. Dr. Shabbir Nasir (Multan)
Prof. Khalid Bashir (Lahore)
Prof. Dr. J. P. Long (UK)
Prof. Dr. Harry Minhas (Australia)
Prof. Dr. Sasleri (UK)
Dr. Zia Farooqi (Lahore)
Maj. Ge. Dr. Naseem-ul-Majeed (Rawalpindi)
Brig. Dr. Mowadat H. Rana (Rawalpindi)
Brig. Dr. Muhammad Ayub (Rawalpindi)
Dr. Zia Farooqi (Lahore)
Prof. Aftab Mohsin (Medicine)
Prof. Sadaqat Ali Khan (Surgery)
Prof. Javed Raza Gardezi (Surgery)
Prof. Muhammad Sarfraz Ahmad (Surgery)
Prof. Mehmood Ayaz ( Surgery)
Prof. Riaz Ahmad Tasnim (Urology)
Prof. Rubina Sohail (Obs. Gynae)
Prof. Sohail Khurshid Lodhi (Obst. & Gynae)
Prof. Rakhshan Shaheen Najmi (Gynae & Obst.)
Prof. Muhammad Ali (Paed. Medicine)
Prof. Ghulam Raza Bloch (Paed. Medicine)
Prof. Sajid Hameed Dar (Paediatric Surgery)
Prof. Ferdose Sultana (Anatomy)
Prof. Ghazala Jaffary (Pathology)
Prof. Ghulam Qadir Fayyaz (Plastic Surgery)
Prof. Rizwan Masood Butt (Neurosurgery)
Prof. Hamid Javed Qureshi (Physiology)
Prof. Kamran Khalid Chima (Pulmonology)
Prof. Shahid Mahmood (Community Medicine)
Prof. Muhammad Amjad (ENT)
Prof. Muhammad Azam Bokhari (Dermatology)
Prof. Muhammad Mujeeb (ENT)
Prof. Muhammad Tayyab (Ophthalmology)
Prof. Muhammad Akram (Anaesthesia)
Prof. Saeed Akhtar Khan (Histopathology)
Prof. Safdar Ali Malik (Radiology)
Dr. Syed Zia-ud-Din (Forensic Medicine)
Dr. Farah Shafi ( Medicine)
Dr. Kaukab Sultana (Biochemistry)
Dr. Khadija Irfan Khawaja (Endocrinology)
Dr. Sobia Qazi (Infectious Diseases)
Dr. Shoaib Nabi (Thoracic Surgery)
Dr. Ahsan Numan ( Neurology)
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Review Board
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Appraisal of General Practitioners in the Management of Acute
Watery Diarrhea for Children Under 5 Years of Age
Muhammad Naeem, Malik Shahid Shaukat, Muhammad Shahid Iqbal and Fayyaz Atif
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Objective: To appraise general practitioners in the management of acute watery diarrhea for
children under 5 years of age and to identify various factors contributing to current practices of
general practitioners for the case management of diarrhea.
Material & Methods: This cross-sectional descriptive study was conducted on 380 general
practitioners (GPs) selected through simple random sampling from the list of GPs working in the
private sector of Lahore city Their knowledge and practices regarding management of AWD for
the children under 5 years of age was determined by using semi structured questionnaire and
data was analyzed using SPSS version 16.0.
Results: Of the 380 GPs working in the private sector of Lahore city, 339 (89%) were males and
41 (11%) were females. GPs with MBSS only prescribed 2.3 ± 1.6 drugs /prescription whereas
pediatricians with minor diploma prescribed 1.9 ± 1.6 drugs/prescription. A statistically significant
difference was observed between qualification of GPs, experience as GPs, knowledge regarding
WHO guidelines, attending courses at DTU and their prescribing trend for ORS, antimicrobials
and anti-diarrheals, and zinc.
Conclusion: The dearth in the knowledge of GPs pertaining to the latest protocols elaborated
by WHO and UNICEF has unearthed a dire need for their continuous medical education under the
stewardship of the Government of Pakistan by allocating essential resources to update the
information level of GPs catering medical services for almost 80% of community.
Keywords: General Practitioners, Continuous Medical Education, Integrated Management of
Childhood Illness, Children under 5 years of age.
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Introduction
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Diarrheal disorders in childhood account for a large
proportion (18%) of childhood deaths, with an
estimated 1.8 million deaths per year globally. The
World Health Organization (WHO) suspects that
there are more than 700 million episodes of diarrhea
annually in children under 5 years of age in
developing countries.1 While global mortality may be
declining, the overall incidence of diarrhea remains
unchanged at about 3.2 episodes per child year. Even
in developed countries like U.S.A, there are 1.5 million
outpatient visits for gastroenteritis, 200,000
hospitalizations, and 300 deaths annually. Globally, it
was estimated in 1999 that Shigella infections may
lead to 600,000 deaths per year of children under 5
years of age, a quarter to a third of all diarrhea related
mortality in this age group.2 Although most cases only
require supportive management and are self limited,
diarrheal diseases remain the fifth leading cause of
death among the global population.3 According to the
USAID Micronutrient Program, 11 million child
deaths occur each year, two thirds of these are
preventable, with widespread use of oral rehydration
salt (ORS) and Zinc supplementation for diarrhea
1
treatment; and many lives can be saved if these
advances are used in conjunction with effective
4
management both in the home and the health facility.
Repeated attacks of diarrhea lead to under nutrition
and poor growth because of reduced food intake
(owing to anorexia and withholding food), malabsorption of nutrients and increased nutrient
requirements. The major cause of death in diarrhea is
dehydration which is associated more with the acute
watery diarrhea (AWD) than the chronic or recurrent
diarrhea. In Pakistan, under 5 mortality rate is
100/1000 live births and deaths due to diarrheal
diseases among children under 5 years is 14% of total
deaths in this age group, whereas in the Eastern
5
Mediterranean region (EMRO), average is 15%. As
far as top ten causes of death in all ages in Pakistan is
concerned, death due to diarrheal diseases is
6
118/1000 (9%) and years of life lost are 12%. This
gives the indication not only of the high incidence of
the disease but also the poor management of
diarrhea in the country.
This study was carried out to appraise the GPs in the
management of acute watery diarrhea for children
under 5 years of age at Lahore city, Punjab
Esculapio - Volume 07, Issue 04, October-December 2011
Pakistan. The knowledge and practices of general
practitioners in the case management of acute watery
diarrhea for such age group according to WHO
guideline was estimated through interviews by the
researcher and observations were assessed in the light
10
of standard protocols elaborated by WHO.
Material & Methods
Results
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This was a cross-sectional analytical study was
conducted at Lahore city between 12th March, 2009
and November, 2009. The study population
comprised of the General Practitioners working in
the private clinics in the Lahore city and sampling
frame comprised of a list of GPs working in the
Lahore city. Sampling unit was a GP working in the
private setting of this city. A sample size of 380 GPs
was calculated according to the data available. List of
GPs working in the private set up was procured
through the courtesy of Pakistan Academy of Family
Physicians, Lahore Pakistan and Pakistan Medical
Association (PMA), Lahore and the number of GPs
included in the universe was 3000. As the study
intended to appraise the GPs in the management of
AWD for the U5, therefore, the sample size was
calculated using the formula for estimating a
proportion. Simple random sampling (SRS)
technique was used. Only qualified GPs working in
the Lahore city, providing medical care in private
sector as family physicians were included.
Data was collected using a semi structured
questionnaire and entered for analysis into the
computer using the SPSS version 16.0. Data was
analyzed for description i.e. for continuous variables
like experience, mean ± standard deviation (SD); and
for categorical variables, frequencies and percentages
were calculated. Chi-square or Fisher's exact test was
used to estimate associations and significant
differences between categorical independent and
outcome variables. Alpha level of 5% (p = 0.05) was
used for significance testing and associations.
workshops. Only 103 (27%) GPs had read WHO/
UNICEF criteria for proper management of AWD.
The response of children toward ORS revealed that
only 153 (40.3%) of GPs stated that children liked to
take it. Drugs prescribing trend depicted that 276
(77.7%) of GPs would prescribe antimicrobial drugs
and 144 (37.9%) GPs would recommend antidiarrheal drugs; out of them, 44 (30.6%) would
recommend it to every patient and 100 (69.4%)
recommended such drugs occasionally. 120 (31.6%)
GPs would prescribe I/V fluids in moderate to severe
dehydration, while 116 (30.5%) considered excessive
vomiting and diarrhea as an indication for this
therapy. Overwhelming majority of GPs i.e. 362
(95.2%) would refer seriously dehydrated cases to
government hospitals and only 6 (1.6%) would refer
such cases to consultants to get appropriate
management. 266 (70%) GPs recommended home
made fluids in case of AWD in U5 children. 160
(42.1%) GPs had belief in the role of micronutrients
in the management of acute watery diarrhea and out
of them only 25 (15.6%) GPs knew the role of zinc in
the management of AWD. It was seen that 191
(50.3%) GPs would recommend continuing feeding
milk only, while 83 (21.8%) recommended feeding
semi-solids plus fluids including milk, whereas, 66
(17.4%) would like to add fluids with milk and only 40
(10.5%) advised solids, semi-solids plus milk in such
cases. 268 (70.5%) GPs were visited by a medical
representative and 165 (61.6%) deposed that there is
no effect on the prescription rate for a particular drug
while 75 (28%) stated in favor of increased
prescription rate for a certain drug and 28 (10.4%)
GPs mentioned about decreased prescription rate.
300 (78.9%) GPs would use to advise their patients
for washing hands before and after taking or serving
food, 322 (84.7%) GPs educated their clients to use
boiled water for drinking and 248 (65.2%) GPs would
use advise the parents of sick children to use cooked
food.A statistically significant difference was
observed between qualification of GPs, experience as
GPs, knowledge regarding WHO guidelines,
attendance of a course at DTU and their prescribing
trend for ORS, anti-microbials, anti-diarrheals, and
zinc.
Of the 380 GPs working in the private sector at
Lahore city, 339 (89%) were males and 41 (11%) were
females. GPs with MBSS only prescribed 2.3 ± 1.6
drugs /prescription whereas pediatricians with minor
diploma prescribed 1.9 ± 1.6 drugs/prescription.
Experience of GPs ranged from less than one to
more than 20 years. 213 (56.1%) of GPs worked in a
pediatric unit while only 130 (34.2%) attended
diarrhea management training course. Overwhelming
majority i.e. 356 (93.8%) never attended such
Discussion
It was revealed from data that additional post
graduate qualification attained by the GPs either in
the form of minor or major diplomas in the field of
pediatrics invariably has its positive impact on the
better and precise case management for the children.
2
Esculapio - Volume 07, Issue 04, October-December 2011
Table-1: Characteristics of respondents.
Medical Qualification
Males (n %)
Females (n %)
Total (n %)
MBBS / MD
268 (79.0%)
37 (90.02)
305 (80.3)
MBBS ± Minor Diploma in pediatrics
07 (2.0%)
-
07 (1.8)
Others
64 (19.0%)
04 (9.8)
68 (17.9)
Total
339 (100.0)
4 1(100)
380 (100)
Table-2: Experience of GPs in pediatric units, trainings at DMTU, attended workshops on diarrhea management,
knowledge regarding WHO criteria, management according to WHO plan.
Total n %
Males n %
Females n %
Yes
207 (61.1)
06 (14.6)
213 (56.1)
No
132 (38.9)
35 (85.4)
167 (43.9)
41 (11)
380 (100.0)
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Work experience
339 (89)
Total
No
223 (58.6)
Total
339 (89.2)
Table-3: Frequency distribution of drugs recommending practices by Gps.
Yes
No
Antimicrobial
296 (77.7)
84 (22.3)
380 (100)
Antidiarrheal
144 (37.9) 236 (62.1)
380 (100)
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Total
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Table-4: Frequency distribution of GPs by their
belief in the role of micro-nutrients (zinc) in the
management of AWD.
Role of micro-nutrients
No. / %
Yes
py
Total
160 (42.1)
Co
No
130 (34.3)
27 (7.1)
250 (65.7)
41 (10.8)
380 (100)
applicable) and > 6 m as weaning starts (sr. no.1 5 applicable)
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Recommended Drugs
14 (3.7)
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116 (30.6)
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Yes
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Training
220 (57.9)
380 (100)
Table-5: Frequency distribution of GPs recommending various types of feeding to the parents for
their children during AWD.
Feeding Recommendation
No. / %
Milk only
191 (50.3)
Fluids + Milk
66 (17.4)
Semisolids + fluids including milk
83 (21.8)
Solids+semisolids+fluids including milk
40 (10.5)
Total
380 (100)
*Feeding recommendations: For the age < 6 months (sr.no. 1 & 2
3
However, this study showed a statistically
qualification and prescription for anti diarrhea drugs
and zinc was found statistically significant. Similar
observations were made by Alam et al where GPs
having major diploma in pediatrics prescribed less
drugs as compared to those with minor diploma in
pediatrics.11 To estimate impact of experience and
postgraduate qualification profile of GPs on their
practicing behavior, in a study by Baqui et al about
drug prescribing practices of general practitioners
and paediatricians for childhood diarrhea, the results
indicated inadequate prescription of ORS and
excessive prescription of antibacterials, antidiarrheals
and antiamebics by GPs. Intervention strategies need
to be planned to improve the prescribing practices of
both groups. 12
Similarly, another study conducted in Kerman, Iran
by Seddique et al showed no significant difference
between physician's knowledge and their
educational/practice level but there was a significant
difference based on years of working experience (less
than 16 years) (p<0.001) with knowledge.13 In order
to ascertain the impact of training programs attended
by GPs on the management of diarrhea at Diarrhea
Management Training Units (DTUs), a retrospective
review of cases seen in the Diarrhea Treatment and
Training Unit (DTU) of Bangalore (India) confirmed
the efficacy of the standard case management
Esculapio - Volume 07, Issue 04, October-December 2011
professionals toward prescribing antispasmodics and
anti-motility agents and their actual prescribing
18
behavior.
A double-blind placebo-controlled study was
designed by Strand TA et al to evaluate the effects of
zinc supplementation on the clinical course and
duration of diarrhea in malnourished Turkish
children. The mean duration of diarrhea was shorter
and the percentage of children with consistent
diarrhea for more than 3-7 days was lower in the study
subgroups than in the control subgroups.19
One of the limitations of this study is that it was
carried out on a particular segment of physicians in a
large urban location; therefore caution needs to be
exercised in generalizing results towards the
population at large. The sample size of 380 was
smaller when it is compared to other studies carried
out on general physicians in the management of
AWD for U5 age group in some other countries
owing to the limitation of resources at our disposal.
Researcher did not carry out diagnostic tests to
quantify some variables of incumbent study as done
by many investigators in other countries that would
have alluded to the levels of our own private set up in
the country but such analysis remains controversial as
the study variables were destined to evaluate the
knowledge and practices of GPs particularly by
targeting their technical skills.
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approach and this strategy entailed importance of
oral rehydration therapy (ORT), continued feeding,
and selective use of intravenous fluids and
antibiotics.14 To appraise the current practices among
the doctors working at filter clinics and diagnostic
centers in Lahore city regarding the management of
acute watery diarrhea (AWD) in children, one study
showed that 94% doctors prescribed ORS in
childhood diarrhea; I/V fluids were prescribed by
40% doctors and 86% would administer drugs.
Although these finding are not consistent with our
study, the only similarity is inclusion of ORS as an
important variable for the management of such cases
although the prescription rate for ORS in our study
was surprisingly low i.e. only 29% of GPs would
prescribe ORS for 90% of children as compared
with 94% in the study under discussion. Similarly,
only 6% of GPs would prescribe IV fluids for 90% of
cases with moderate to severe dehydration and 9% of
GPs would prescribe drugs for 90% of children in
our study. It was concluded that although many
doctors are familiar with WHO guidelines for
management of childhood diarrhea, most of them
are not following the recommendations in true letter
15
and spirit. As shown in a study by Oingwen W et al
regarding management modalities of diarrhea, three
grade health education models for the training of
health workers and caretakers was developed to
improve the knowledge, attitude and practice in
diarrhea disease. It showed that rate of ORS use was
increased; the rate of IV use, antibiotic and
antidiarrheal drug use was decreased obviously. The
16
difference was statistically significant (p < 0.05).
Analysis of results pertaining to prescription of ORS
by GPs and different factors studied showed that
there was a statistically insignificant difference
between prescribing trend of GPs and their medical
qualification. A statistically significant association was
found between the year of graduation, the experience
of in child care and knowledge about WHO guide
lines for the management of diarrhea, while no
statistically significant association was seen between
GPs prescribing ORS and their working experience in
a pediatric unit. In order to assess knowledge of
diarrhea management by GPs, a study by Patwari et al
showed that 91% of GPs were prescribing ORS in
various combinations, but only 9.8% were advising
ORS and feeding as standard management of
diarrhea.17
The findings of our study are consistent with the
study conducted by Nizami S et al which depicted that
inconsistencies exist in stated attitudes of health
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Conclusion
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On the basis of the results of study, it can be
concluded that there are gaps in the knowledge and
practices of GPs regarding management of acute
watery diarrhea in the children under five years of age.
The dearth in the knowledge of GPs pertaining to the
latest protocols elaborated by WHO and UNICEF
has unearthed a dire need for their continuous
medical education under the stewardship of the
Government of Pakistan by allocating essential
resources to update the information level of GPs
catering medical services for almost 80% of
community. Although the information that AWD
should be managed with ORS and without use of
drugs, seemingly has reached the majority of GPs
their practices is not according to this knowledge. The
reason behind this could be lack of awareness in the
fact that ORS plus zinc alone can manage AWD
which is further strengthened by the demand of
drugs by parents, competition in practice, influence
of pharmaceutical representatives coupled with
absence of supervisory control on prescription. DTU
course, training workshops have not been able to
4
Esculapio - Volume 07, Issue 04, October-December 2011
produce any significant effect on GP's knowledge and
practices for the management of AWD.
There should be more appraisal studies at national
level to determine the true estimate of knowledge and
practices of GPs for the management of diarrheal
diseases in the children under five years of age.
Government of Pakistan should consider conducting
Diarrhea Management Training Courses, workshops
as an ongoing program, under the supervision of
experts, to update the knowledge and skills of
privatepractitioners. Continuous Medical Education
(CME) and Community Oriented Medical Education
(COME) need to be inculcated in national health
policy for the General Practitioners working in the
private set up for capacity building.
Department of Infectious Diseases
Institute of Public Health, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
47:7-11.
Kundi MZ, Ahmad I, Anjum M.
Evaluation of diarrhoea management of health professionals
trained at the Diarrhoea Training
Unit of Rawalpindi General
Hospital. J Pak Med Assoc 1997;
47:3-6.
Gupta MC, Mahajan BK. Text
book of preventive and social
medicine. 3rd ed. New Delhi:
Jayp ee Bro th ers Med i ca l
Publishers, 2003; p.193.
World Health Organization. A
manual for the treatment of
diarrhea. Program for control of
Diarrhoeal Diseases. Geneva:
World Health Organisation,
(WHO/CDR/95.3), 2004.
Javed M. Audit of pediatric
prescriptions for the common
paediatric problems. Pak J Med Sci
2007; 23: 932-5.
Baqui AH, Black RE, Arifeen S,
Yunus M, Zaman K, Begum N, et
al. Zinc therapy for diarrhoea
increased the use of oral
rehydration therapy and reduced
the use of antibiotics in
Bangladesh children. J Health
Popul Nutr 2004; 22: 440-2.
Seddiqe AR, Babak B. Physicians'
knowledge regarding nutritional
14.
15.
16.
gh
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11.
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1. Bhutta ZA. Acute gastroenteritis
in children. In: Nelson textbook
o f p e d i a t r i c s. 1 8 t h e d .
Philadelphia: Saunders, 2008;
p.1605.
2. Camelleri M, Murray JA. Diarrhea
and constipation. In: Braunwald
E, Hauser SL, Fauci AS, Longo
DL, Jameson JL editors.
Harrison's principles of internal
medicine.17th ed. New York:
McGraw-Hill, 2008; p. 245.
3. Valls V. Acute gastrointestinal
infections. In: Robert B, Wallace
editors. Maxcy-Rosenau-Last.
Public health & preventive
medicine. 15th ed. New York:
McGraw Hill, 2008; p.263-9.
4. WHO/UNICEF. Joint statement
on the clinical management of
acute diarrhea. 2004.
5. Mortality country fact sheet,
WHO Eastern Mediterranean
Region Pakistan; World Health
Statistics: 2006.
6. UNICEF. The state of World's
Children, Child Survival. 2009;
p.8.
7. Ibrahim S, Isani Z. Evaluation of
doctors trained at Diarrhea
Training Unit of National
Institute of Child Health,
Karachi. J Pak Med Assoc 1997;
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References
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management in children with
diarrhea: a study in Kerman, Iran,
Pak J Nut 2007; 6: 638-40.
Kamla CS, Vishwanahtakumar
HM, Shetti PM. Diarrhea
Treatment Unit Banglore. Indian
J Pediatr 2004; 41: 255.
Tabassum MN, Khan HI,
Ahmad TM. Current practices of
general practitioners towards the
management of acute watery
diarrhea in children up to 5 years
of age. Pak J Paediatr 2003;27:5662.
Qingwen W, Aihong Z, Jianying
Li, Huali C, Jingzhi Ji, Lili Q et al.
A study of managed case for
diarrhea disease. J Evidence
Based Med 2002; 2: 13-18.
Patwari AK, Kumar H, Anand
VK. Diarrhea training and
treatment centre. Indian J
Paediatr 2008; 58: 775-81.
Nizami S, Khan IA, Bhutta ZA.
Risk factors of acute watery
diarrhea. Pak J Med Res 2001; 40:
126.
Strand TA, Chandyo RK, Bahl
R. Effectiveness and efficacy of
zinc for the treatment of acute
diarrhea in young children. Ind J
Pediatr 2002; 109: 898-903.
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Carbonated Drink Consumption And BMI In Pakistani Adolescents
Reema Iram, Sibgha Zulfiqar, Samina Malik and Muhammad Bilal
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Objective: To evaluate the relationship between intake of carbonated drinks and weight gain
among adolescent Pakistanis.
Material & Methods: This comparative study was carried out in urban district of Lahore and
total of 270 adolescents 13-15 years of age were studied. Weight and height was measured with
2
Height and Weight Measuring Scale (SMIC). Obesity was assessed by BMI (wt (kg)/Ht (m ).
Carbonated drinks consumed per week were measured using a self administered Food
Frequency Questionnaire (FFQ).
Results: There was no significant difference between the intake of carbonated drinks in normal,
overweight and obese adolescents.
Conclusions: Carbonated drink consumption cannot be held responsible for increase in BMI
unless combined with other factors.
Keywords: Carbonated drinks (CD), Food Frequency Questionnaire (FFQ), Body Mass Index
(BMI)
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Introduction
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Obesity has recently emerged as a global health issue
among the young population. Studies have shown
that the problem is worsening rapidly. Scientists have
reported the prevalence of rising obesity both in
1
developed and under developed countries. Adults
who were obese as children are more liable to suffer
from ill health.2 Obesity has been shown to be
associated with many chronic diseases leading to
compromise on health. Many environmental factors
have been suggested as the precipitating factors for
the obesity epidemic.3 One such factor may be
increased consumption of carbonated drinks. Several
researches regarding childhood and adolescent
obesity have been carried out in the western
4
countries. US studies have revealed there has been a
three times increase in the intake of soft drinks in the
5
last few decades. There is a huge disparity regarding
the consumption of carbonated drinks and obesity
incidence in the western population. However its
importance has been less documented in developing
countries including Pakistan. There is a dire need to
study a relationship, if any between consumption of
carbonated drinks and its effect on BMI.
the urban district of Lahore. 135 were males and 135
were females. Each of these were further grouped
into normal, overweight and obese according to the
international cut off points of BMI.
After taking consent from each subject on a
performa, following measurements were taken.
1. Weight was measured to the nearest 0.1 kilogram
with height and weight measuring scale (SMIC) in
kilograms.
2. Height was measured to nearest 0.1 cm with the
same machine. These measurements were used
2
2
to compute BMI = weight/ height (kg/m )
3. Carbonated drinks consumed per week were
measured using a self administered food
frequency questionnaire (FFQ). Beverage
categories included were Pepsi cola, Coca cola,
Seven up, Fanta, Mountain Dew and Sprite.
One way ANOVA was used to determine the
significance of the difference in consumption of
carbonated drinks in normal, overweight and obese.
Results
The mean number of carbonated drinks consumed
was 3.2 in normal, 3.88 in obese and 4.45 in
overweight. Normal weight subjects consumed 0 to
21 drinks while obese consumed 0 to 21 and the over
weight consumed 0 to 28 drinks per week (Table 1).
There was a no significant difference in the number
of carbonated drinks consumed in normal, over
weight and obese per week (F=1.994, df = 2, p >
0.138) (Table 2).
Objective
To find out association between intake of carbonated
drinks and weight gain in adolescents 13 to 15 years
old.
Material & Methods
This cross sectional comparative study was carried
out on a total of 270 adolescents, 13-15 years of age in
6
Esculapio - Volume 07, Issue 04, October-December 2011
Table-1: Carbonated drink consumption per week in normal, obese and overweight.
N
Mean CD
Std. Deviation
Std. Error
Normal
90
3.2000
3.81364
.40199
95% Confidence Interval for Mean
Lower Bound
Upper Bound
3.9988
2.4012
Obese
90
3.8889
4.19053
.44172
3.0112
Overweight 90
4.44556
4.63053
.48810
Total
3.8481
4.24035
.25806
270
Min
Max
.00
21.00
4.7666
.00
21.00
3.4857
5.4254
.00
28.00
3.3401
4.3562
.00
28.00
Table-2: Comparison between carbonated drink consumption in normal, overweight and obese.
df
Mean Square
Between Groups
71.163
2
35.581
Within Groups
4765.611
267
17.849
Total
4836.774
269
1.994
p-value
.138
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Discussion
F
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Sum of Squares
But association was not statistically significant in girls.
This was a cross sectional study performed on a large
number of subjects. Another cluster randomized
controlled trial in Southwest England showed that
reduction of carbonated drink consumption was
associated with reduction in number of overweight
and obese children. Limitation of this study was that
the validity of self collected dietary data can be
questioned owing to tendency for under reporting of
energy intake, particularly by those who are
overweight and obese.
ts
@
Es
cu
The results of the present study showed that the
consumption of carbonated drinks was not
associated with BMI both in female and male
adolescents. The results of the current study coincide
with other studies. For example Forshee et al found
no statistically significant association between
carbonated drink consumption and BMI in
adolescent males and females using data from Third
National Health and Nutrition Survey. There was no
significant difference in body mass index between
drinkers and non drinkers (p=.05) in adolescent girls
of United Arab Emirates reported by Mahmood et al.
Another study found no significant association
between consumption of carbonated drinks and BMI
in adolescents. There was no difference in percentage
of energy from soda between obese (6 ± 4.9%) and
non obese (5.9 ± 4.96). Studies by Bandini et al and
Mahmood et al are similar to the present study being
cross sectional and are performed on adolescents. On
the other hand although NHANES was a longitudinal
study on adolescents, it is in line with the present
study. So although all these investigations were
conducted in different geographical and cultural
backgrounds on different races with different eating
habits, they are in line with the present study showing
the universality of results. Conversely Kate et al
found a positive association between BMI and sugar
sweetened carbonated drinks in males (p<0.0001)
Conclusion
Co
py
Ri
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This study elucidates that carbonated drink
consumption alone cannot be held responsible for
the obesity epidemic. Although carbonated drink
consumption may contribute to the total energy
intake of adolescents but other lifestyle behaviors like
eating high calorie food and decreased physical
activity also affect BMI. Consequently it is difficult to
ascertain whether the weight gain results from
consumption of calories from carbonated drinks,
food or from variation of physical activity.
Department of Physiology
Fatima Jinnah Medical College, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
References
1. Dietz WH, Bellezzi MC. The use
of body mass index to assess
obesity in children. Am J Clin
2.
Nutr 1999;70: 123-5.
Wang XL, Wilcken DEL. Body
mass index in Australian children :
7
recent changes and relevance of
ethnicity. Arch Dis Child 2000;
82:16-20.
Esculapio - Volume 07, Issue 04, October-December 2011
3. Donohoue PA. Obesity. In;
Behrman RE Kliegman RM
,Jenson HB.Nelson ed. Textbook
of Pediatrics 17th edn. Philadelphia;Saunders,2004:173-6.
4. Fredriks AM, Buuren SV, Veit JM,
Vanhorick SPV. Body index
measurements in 1996-97
compared with 1980. Arch Dis
Child 2000;82:107-12.
5. Troiano RP, Briefel RR, Carroll
MD, Bialostosky K. Energy and
fat intakes of children and
adolescents in the United States:
data from the National Health
and Nutrition Examination
Surveys. Am J Clin Nutr 2000;72
(suppl): 1343S53S.
6. Forshee RA, Anderson PA, Storey
Khalid A, Shoukri M. Sugarsweetened carbonated beverage
consumption correlates with
BMI, waist circumference, and
poor dietary choices in school
children. BMC Public Health.
2010;10: 234.
11. James, J, Thomas, P, Cavan, D,
Kerr, D. Preventing childhood
obesity by reducing consumption
of carbonated drinks. BMJ 2004;
328: 12-37.
12. Campbell K, Waters E, O'Meara
S, Summerbell C. Interventions
for preventing obesity in
children. Cochrane library, Issue
1. Oxford: Update Software,
2001.
lap
io.
pk
ML. The role of beverage
consumption, physical activity,
sedentary behavior, and demographics on body mass index of
adolescents. Int J Food Sci Nutr.
2004 Sep;55(6):463-78.
8. Mahmood M, Saleh A, Al-Alawi
F, Ahmed F. Health effects of soda
drinking in adolescent girls in the
United Arab Emirates. J Crit Care.
2008 Sep;23(3):434-40.
9. Bandini LG, Vu D, Must A, Cyr H,
Goldberg A, Dietz WH.
Comparison of high-calorie, lownutrient-dense food consumption
among obese and non-obese
adolescents. Obes Res 1999; 7:
438-43.
10. Kate S C, Marya Z, Shazia N,
cu
PICTURE QUIZ
Co
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Ri
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ts
@
Es
This 52 years old man is a known case of coronary artery disease and had undergone CABG 2 years ago. He was
taking his medication regularly and was symptom free. Lately he noticed that his skin colour changed but
completely ignored it. He then developed bleeding from gums and nose for which he consulted his GP. Next day
he presented to the hospital with massive upper GI bleeding. Examination revealed pigmentation as shown in
the picture. Blood test showed HB 11.2 G/dl; TLC 1,900; and platelet count 12,000 only. Gastroscopy was
performed that showed a picture of erosive gastritis. Dengue serology was negative. Bone marrow aspiration
was done which showed marked hypoplasia but no infiltration by other cells.
Question: What is the diagnosis? How do you explain the blood picture? How will you treat him?
See answer on page no. 23
8
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Bullying Among Primary School Children
Khaula Shamim, Asma Ajlas, Tasneem Fatima Rana, Maria Butt, Samina Khalid, Ifleen Asghar and Tajammal Mustafa
Objective: To study different forms of bullying and its effects on primary school children
Material & Methods: This cross sectional study was conducted in three primary schools in
lap
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pk
Mozang and Samanabad areas of Lahore. Data was collected by interviewing each student using
a structured questionnaire. SPSS 17.0 was used for data entry and analysis.
Results: A total of 414 primary school children participated in the study. Seventy four percent of
the students reported having being bullied in one form or the other. Frequency of bullying was
higher among males than females. The major types of bullying were, teasing (37.5%), hitting
(42.7%), and calling names (34.9%).
Conclusion: Bullying is an ever rising phenomenon in our society. It is a significant mental and
social health problem in primary school children in Pakistan. It affects students’ right to learn in
safe and secure environment.
Keywords: Bullying, School children, Students, Relationship
Introduction
Co
py
Ri
gh
ts
@
Es
cu
Bullying is defined as use of power and aggression to
cause distress and control others. It can be
categorized into two forms, direct and indirect. Direct
would include use of expression of power through
physical aggression (e.g. hitting, kicking) and verbal
aggression (e.g. insults, racial or sexual harassment,
threats). Indirect bullying (relational aggression) is the
manipulation of social relationships to hurt (e.g.
gossiping, spreading rumors) or exclude the
individual being victimized.
Two elements of bullying are key to understanding its
complexity. First, bullying is a form of aggressive
behavior imposed from a position of power. Children
who bully have more power than the children they
victimize, and this power is often not evident to
adults. Children's power can derive from a physical
advantage (such as size and strength) or from a social
advantage (such as a higher social status in a peer
group or strength in numbers). The second key
element is that bullying is repeated overtime, and with
each repeated incidence, the power dynamics become
consolidated. Research reveals bullying as a
destructive relationship problem.
Bullying can lead to numerous health problems.
Children who are bullied are likely to develop both
physical and psychological symptoms. Physical
symptoms that are commonly experienced are
headaches, stomachaches. Psychosomatic symptoms
are also experienced (such as difficulty in sleeping or
bed-wetting).
Bullying is a social phenomenon that transcends
gender, age and culture. While there are wide ranges in
the definition of the term, bullying is essentially
characterized by one or several individuals aggressing
on a vulnerable peer, primarily to assert control or
power. The aims for our research was to increase our
knowledge about bullying in primary school children
in Pakistan, to study prevalence of bullying in school
children, to determine different forms and types of
bullying, and the areas where bullying took place.
History and review shows that bullying as a separate
offence has been recorded in recent years but there
have been well documented cases recorded earlier.
Previous records, Newgate calendar, shows it as early
as 1700, when two Eton scholars were charged for
1
killing and slaying of their new fellow students.
Pediatric case records showing frequent headaches,
tummy aches, poor sleeping and bedwetting had been
2
reported due to bullying. Evidence suggests that in
the United States, the incidence of bullying among
children is increasing and becoming a nationwide
problem. One out of five children admits to being a
3
bully.
The patterns of bullying in females and males have
been worked out by Roland et al (1989) showing that
boys resort to physical means and girls employ
psychological methods such as exclusion. Girls tend
to bully less as they get older. The percentage of boys,
who bully, however is similar at different age levels.4
Twenty five to fifty percent of children report being
bullied as mentioned in one study. The great majority
of boys are bullied by other boys while sixty percent
of girls report being bullied by other boys. Eight
percent of children report staying away from schools
one day per month because they fear being bullied.
Forty three percent of children have a fear of being
5
harassed in the school bathroom.
9
Esculapio - Volume 07, Issue 04, October-December 2011
Table-1: Basic demographic data.
Material & Methods
Study Area/Population
A cross-sectional study was conducted in primary
school children in three schools, in Mozang and
Samanabad area in the city of Lahore. Convenient
sampling was done. Sampling was based on socioeconomic status, according to which two public
schools were chosen falling in the low socioeconomic group and one private school falling in the
high socio-economic group. Study was carried out in
students belonging to the first, fourth and the fifth
grade. Some sections were selected randomly and all
the students in the same section were included. Data
was collected using standardized questionnaire and
students were interviewed in person. The
examination was conducted by a doctor.
Headmistresses of the schools were contacted. Their
permission was sought. For primary school children,
informed consent was taken from the parents. Only
those who got that were interviewed. The interview
th
was conducted by 4 year medical students, Fatima
Jinnah Medical College, Lahore. Information was
collected on basic demographic characteristics such
as age, sex, education, occupation, area where they
lived. Information was also collected on specific
study characteristics such as teasing, physical abuse,
threatening, calling offensive names, snatching things
and the places where these events occurred.
Bullying was defined as teasing, physical abuse,
threatening, calling offensive names, and snatching
things.
The variable under study was bullying in primary
school children and it was analyzed as a categorical
variable. Entry of data was done using SPSS 16. Data
was analyzed initially using frequency distributions.
Odds ratios were calculated to measure associations.
To test for statistical significance, chi square was used.
Name
Age (n=414)
5-6
80
19.3
7-8
162
39.1
9-10
172
41.6
Male
222
53.7
Female
192
46.3
53
12.8
Non professional
345
83.4
Don’t work
16
03.8
House wife
13
75.6
Working
53
12.8
09
0.2
1-3
264
63.9
4-5
150
36.1
Total
414
100
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pk
Gender (n=414)
Father’s Occupation
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Professional
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Mother’s Occupation
Deceased
ts
@
Classes (n=414)
Ri
gh
Table-2: Different forms and places of bullying
experienced by primary school children.
Number
Percentage
Yes
307
74.2
No
107
25.8
Teased
115
37.5
Called names
107
34.9
Hit
131
42.7
Snatched things
71
23.1
Scared
55
17.9
Asked for money
48
15.6
Near home
128
41.7
During class
120
39.1
Bullied (n=414)
py
Results
Percentage
Co
The study population consisted of 414 primary
school students, aged 5-10 years from three different
schools of Lahore, Pakistan. Out of these 414
students, 172 (41.6%) belonged to the age group 9-10
years, 162 (39.1%) were of 7-8 years and 80 (19.3%)
were in the age group of 5-6 years. 264 ( 63.9%) of the
students were studying in classes 1-3 at that time and
150 (36.1%) in class 4-5. The frequency of bullying
was higher in males compared to females.
Out of 414 students, 307 were bullied in one form or
the other. The frequency of hitting was the highest
with 42.7% of the students experiencing it (Table 2).
Calling names and teasing were other forms of
bullying that were commonly experienced.
Forms of bullying (n=307)*
Places of bullying (n=307)*
10
Esculapio - Volume 07, Issue 04, October-December 2011
During games
88
31
In school outside class
Discussion
28.7
10.1
Some where else
17
* Multiple responses possible
In our study we found out that bullying is an ever
rising phenomenon in our society. It has become a
significant social and mental health problem in
primary school children in Pakistan. During our study
we found out that bullying affects a vast majority of
young children. It has a negative impact on school
climate. It affects student's right to learn in safe and
secure environment. There are both physical and
psychological implications of bullying.
In contrast to previous studies on bullying, we also
found out the different forms of bullying and abuse.
Fear of stranger was also part of our study. However,
our study group was limited and study participants
were chosen conveniently from primary schools.
Multiple forms of bullying exist in our society such as
teasing, hitting, scaring, snatching things, asking for
money and others. Children respond differently by
screaming, running away, telling some elder or police
etc.
5.5
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pk
Students also reported snatching of things, and were
forced to give their money in some instances. Bullying
took place near home, in classrooms, during games
time and in between classes. Overall bullying was
higher near homes with 128 (41.7.%) students
reporting it. (Table 2)
Table-3: Stranger anxiety and subsequent reactions.
Percentage
Number
29.7
No
228
55.1
Don’t know
12
02.9
Missing
51
12.3
Screamed
8
1.9
Ran away
20
Told someone
50
Anything else
1
1.7
0.2
We recommend that steps should be taken to make
the school environment safe and healthier for
students to function more efficiently and in a
productive way.
There should be a constant system of vigilance and
supervision by the teachers and the staff to prevent
the occurrence of bullying.
Special attention should be paid to improve peer
relationship.
Bullies should be recognized and disciplined and
victims should be provided support and counseling.
Ri
* Multiple responses possible
12.1
ts
7
19
gh
Did not tell anyone
Recommendations
@
Reactions
cu
123
Es
Yes
lap
Has experienced fear of stranger (n=414)
Students were also asked about stranger fear and their
subsequent reaction. 123 reported being scared of
strangers (Table 3). Most of the students chose to
run away or reported the incidence to some adult. A
very small percentage of students (1.7%) did not tell
anyone (Table 3).
py
Department of Community Medicine
Fatima Jinnah Medical College, Lahore
Co
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
References
1. Spriggs AL, lannotti RJ, Nansel
TR, Haynie DL. Adolescent
bullying involvement and
perceived family, peer and school
relations: commonalities and
differences across race/ethnicity.
J Adolesc Health. 2007;41:283-93
2. Brunstein Klomek A, Marrocco
F, Kleinman M. Bullying,
depression, and suicidality in
adolescents. J Am Acad Child
Adolesc Psychiatry. 2007;46:40-9.
3. Stein JA, Dukes RL, Warren JI.
Adolescent male bullies, victims
and bully-victims: a comparison
of psychosocial and behavioral
characteristics. J Pediatr Psychol.
2007;32:273-282.
4. Gini G. Associations between
bullying behavior, psychosomatic
11
complaints, emotional and
behavioral problems. J Pediatr
Child Health.2008 Sep; 44 (9):
492 -7.
5. Volk A, Craig W, Boyce W, King
M. Adolescent risk correlates of
bullying and different types of
victimization. Int J Adolesc Med
health. 2006;18:575-86.
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Mobile Phone Usage Among Female College Students
Noor ul Ain Butt, Chaman Nasrullah, Hina Aslam, Sumaira Akram, Tasneem Kauser and Tajammal Mustafa
Objective: To assess the prevalence and patterns of mobile phone use among female college
students.
Material & Methods: The colleges were selected by convenient sampling and grades were
Es
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pk
selected randomly. The study population was 332 female students. The data was collected using
questionnaire. The research was carried out by the doctors of community medicine department of
Fatima Jinnah Medical College Lahore.
Results: Three colleges having total of 332 female students were surveyed for this research
purpose. A significant proportion of this study group (85.5%) was found to be using mobile
phones. Monthly mobile phone expenditure of 31.3% students was 100-200 rupees. 38%
students were sending less than 20 messages per day. Over 39.8% students used their mobiles
for less than an hour per day. So far as features of the mobile phone and their use were
concerned, text messaging was the most frequently used feature (63.6%). 10.2% of the students
were in the habit of using mobile phones during their classes whereas only 13.9% students
contacted their parents through mobile more than once per day.
Conclusion: The above research depicted extensive use of mobile phone among female
college students. Majority of the students were not using mobile phone during the class .The
students used mobile to chat with their friends through messaging and their expenditure and time
spent on phone was reasonable. Few of the girls were using mobile to contact their parents.
Keywords: Mobile, Phone usage, College students
@
Introduction
Co
py
Ri
gh
ts
There has been a significant increase in the use of
mobile phone during the last decade. Growing
benefits of mobile phone are undeniable. Different
studies have highlighted the advantages of mobile
phone use such as young people use it to keep in
touch with friends and parents (Chakraborty, 2006),
to receive emergency information over a cell phone
(Kay H, Braguglia, Hampton University). There is a
sense of security and safety among the mobile phone
users as they can contact in case of emergency (Taylor
and Harper 2001).
Metrics, an organization that conducted a survey on
mobile phone usage reported the high involvement
of the age group 13-24 years in using mobile phone.
As time is passing by many problems due to use of
mobile phone are coming to surface among
teenagers. Students report that cell phones distract
them during study time outside the class and they
believe that cell phones do not assist them in learning.
Bad or upsetting news received over a cell phone
affects the ability to concentrate (Kay H, Braguglia,
Hampton University). Addiction towards mobile
phone would cause students to experience symptoms
like anxiety, depression and lack of sleep (Sheeren and
Rozumah).
12
With cellular phones, teaching has turned into high
tech. Students can text message the answers to tests,
take pictures of tests or search internet for answers
(Walson, 2006). All schools formally restrict mobile
phone usage but it is common for students to bring
mobile phones in college claiming that they use clock
function only. Although students do not use voice
communication during classes, they read and send
messages during classes (Ito, 2006). Usage rate among
the students is 1.5 to 5 hours/day and average bill per
month is $140 which is very expensive given the low
student income (James and Drennan 2005).
A study by researchers in Australia shows that
increased cell phone use is connected with cognitive
function in young adults. Specifically the study found
that “the accuracy of working memory was poorer,
reaction time for a simple learning task shorter,
associative learning response time shorter but less
accurate working memory.”
A group of Japanese students were surveyed about
their cell phone use and their friendships. About half
of them had cell phones and were more likely to have
friends who also had cell phones. Researchers found
that some of the students display symptoms of
dependency; a no. of students felt that they could not
Esculapio - Volume 07, Issue 04, October-December 2011
go without their cell phones and that their phones
interfered with the schedule. More than half of the
students without cell phones wanted one. The
authors point out that it is possible that students feel
left out socially if they do not have a cell phone.
Telecom sector in Pakistan is growing at a fast pace.
Mobile subscribers are 95.4 million (58% of total
population) as of July 2009, the highest penetration
rate in South Asian Region.
Like other countries youth of Pakistan is among the
high users of mobile. A study by Journal of Pakistan
Psychiatry society has revealed that excessive mobile
usage leads to behavioral changes, here is an extract;
“recently, a dozen school and college girls were
brought to author's clinic by parents, for mobile
addiction. All these girls have failing grades, reported
to be mostly absent from their classes spending most
of the time chatting on mobile phones or sending text
messages to their friends (mostly boys). They were
irritable, rude and belligerent in their behavior and
spent all night talking on phone. Antisocial behavior
like stealing money, roaming around with boyfriends
during school or college hours and precocious sexual
activities were fairly common in these girls.”
The mobile phones, these days have the facilities of
web, GPRS, SMS, MMS, MP3 players, games, radio
etc.; they also offer low call rates and messaging
packages. These accessories have played quite an
important role in detracking the young generation
from their actual responsibilities. Research work has
been done on mobile usage in Australia, USA, India,
UK and other countries. Not much emphasis has
been paid to the adolescents of Pakistan.
The objective of this study was to see in what ways
Pakistani female undergraduates use mobile phone.
This study is an attempt to determine (1) the status of
ownership among students; (2) time spent on using a
cell phone, (3) features most frequently used, (4)
frequency of contact with parents, (5) monthly
expenditure on cell phone. Shedding light on such
topics may bring in notice the excessive or
inappropriate use of this technology to the college
administration, instructors and parents.
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pk
332 students. Permission was taken from the
principals of the respective colleges to conduct the
study. The relevant data was collected through a predesigned questionnaire. Participants were read a
permission note, telling them about the significance
of the study and asking for their permission. The
questionnaire was filled by the researcher herself
while interacting with each participant face to face.
The time spent in filling each questionnaire was
approximately 10-15 minutes. Information was
collected about whether they used mobile phones or
not; what are their expenses, the approximate hours
spent on calls, the mobile phone features mostly used
by them, the frequency of using mobile phone during
classes and for contacting their parents. Data was
analyzed using Statistical Package for Social Sciences
(SPSS), version 16.0. Descriptive analysis was done to
summarize information by calculating the frequency
distributions for categorical variables, whereas the
means and standard deviations (S.D.) were computed
for continuous variables. For categorical variables
measure of association was Chi-Square test. For
continuous variables, measure of association was
student’s t test.
Co
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ts
@
Results
The study was conducted among female college
students of three public sector colleges. The study
population was 332 and most of the participants were
from 3rd and 4th year. Majority of the students
(83.1%) were between 18-20 years of age and had
more or less four siblings (54.7%). Among the
parents, fathers were more educated (95.1%) as
compared to mothers (88.2%) and were doing private
jobs (40.5%) while most of the mothers were
housewives (90.6%). (Table-1) The maximum
percentage of students (31.3%) were spending 100200 rupees per month. 20.8% were using less than 100
rupees, 15.4% were spending between 200-300
rupees per month whereas 17.5% were having
expenditure more than 300 rupees. (Table- 3)
Table-1:Demographic features of female college
students.
Material & Methods
Feature
This cross sectional study was conducted in three
female government colleges located in the areas of
Garhi Shahu, Waris Road and Jail Road in the city of
Lahore. These are one of the populous areas of the
city where the female students usually come from
middle class. The technique used for sampling was
convenient sampling and the size of the sample was
Frequency
Percentage
Age (Years)
13
15- 17
20
6
18 - 20
276
83.1
21 - 23
30
5.9
Missing
16
4.8
Esculapio - Volume 07, Issue 04, October-December 2011
were sending more than 100 messages. Only 7.2% of
the students were not availing this facility at all.
(Table 4) The time spent by students using mobile
phone varied from less than an hour to more than ten
hours daily. Over 39.8% use their mobiles for less
than an hour, 24.7% from one to three hours and 6%
for ten or more hours daily. (Table 5)
Class
3
.9
2nd Year
2
.6
3rd Year
195
58.7
4th Year
127
38.3
Govt. APWA College
138
41.6
Queen Mary College
121
36.4
Table-4: Text messages/day.
College
73
22
5
1.5
None
184
54.7
≒8
134
40.3
9
Total
68.7
6 - 10
87
26.2
> 10
12
3.6
@
ts
The results of the study indicate that among the 332
girls surveyed 85.5% own a mobile and only 8.1% do
not. (Table 2) 38% of the students were using mobile
phones to send less than 20 messages per day;
whereas 13.9%
Missing
Total
gh
Ri
85.5
27
8.1
21
6.3
332
100
Co
No
284
Frequency
Percentage
69
20.86
100-200
164
31.3
200-300
51
15.4
>300
58
17.5
Missing
50
15.1
Total
332
100
<100
332 (100)
The mobile sets of more than 80% of the students
had the facility of clock, calendar, SMS and games.
About 50% were having camera, internet, email,
calculator and mp3. 41.3% were also using headsets.
(Table 6-A) 81.6% of the students used the facility of
text messages and amongst these, 63.6% used it more
frequently as a source of communication. 38.3%
preferred making a voice call, of which 17.8%
frequently used this feature. Besides using mobile
phone for communication, students were using
mobile phone for recreational purposes such as music
Time spent (hrs.)/day
<1
Frequency (%age)
132 (39.8)
1-3
82 (24.7)
4-6
30 (9)
7-9
28 (8.4
> or equal to 10
Missing
Total
Table-3: Monthly mobile phone expenditure.
Monthly Expenditure
46 (13.9)
Table-5: Time spent (hrs.)/day.
Percentage
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Yes
31 (9.3)
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228
Frequency
53 (16)
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2.7
1-5
Mobile Phone Users
126 (38
Missing
No. of Rooms
Table-2: Mobile ownership.
100-200
>300
≒4
≒12
24 (7.2)
200-300
Siblings
Frequency (%age)
Not at all
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Govt. Jinnah Degree College
Text Messages/day
io.
pk
1st Year
20 (6)
40 (12)
332 (100)
(43.7%), games (28.6%) and camera (29.2%). Only
few students were availing the facility of internet
(2.4%) and email (3.3%). (Table 6-B) 10.2% of the
students were daily users of mobile phone during
their classes and 5.4% used it in every class. 63.6% of
the students abstained from using mobile phone
during lectures. (Table 7)
Contact with parents more than once a day was
reported by 13.9% of the students. 11.1% were in
14
Esculapio - Volume 07, Issue 04, October-December 2011
Table-6a: Mobile phone features (%age).
Features Present
Freq.(%age) Features Present
Freq. (%age)
Clock
285 (85.8)
Internet
171 (51.5)
Calendar
287 (86.4)
Mp3/FM
227 (68.4)
SMS
285 (85.8)
Games
267 (80.4)
Calculator
219 (66)
Camera
160 (48.2)
Email
176 (53)
Headset
137 (41.3)
127
(38.3)
SMS
271
(81.6)
Music
145
(43.7)
Games
95
(28.6)
Internet
8
(2.4)
Camera
97
(29.2)
Email
11
(3.3)
Others
7
(2.1)
Table-7: Mobile phone use during class.
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Percentage
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Frequency
Feature
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Table-6b: Mobile phone feature use (%age).
@
Frequency(%age)
Use during class
210 (63.3)
Not at all
18 (5.4)
ts
Every class
Daily
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34 (10.2)
Weekly
19 (5.7)
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Monthly
6 (1.8)
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daily contact with their parents. 57.8% did not use
mobile phone for contacting their parents at all.
(Table 8)
Discussion
(Sheeren and Rozumah). But 33% of the students
were spending around 300 rupees per month
although their parents did not earn much and they
had more or less 4 siblings who might be using the
mobile too thereby adding a significant amount to the
household expenditure. In many colleges the usage of
mobile phones in classrooms is banned in order to
prevent the distraction of students. In our study very
few students were using the mobile phone during
every class (5.4%) and a huge number did not use
mobile phone at all (63.6%). On the contrary in a
study by Kay H, Braguglia 53.5% of students were
using mobile phones during every class in Hampton
University. The feature most commonly used for
communication among Pakistani students is text
messaging (63.6%) whereas in study by Kay H
students used voice call (66.2%) to communicate with
their family and friends. This may be because
different SMS packages for students are launched
from time to time making this feature cheaper as
compared to voice calls in our country.
Our study has highlighted that students although
having highly sophisticated technology like internet
or email available on their mobile phones did not use
it for browsing and educational purposes. It also
conforms to the study of Kay H. Braguglia where
internet was used by 3.6% of the students and email
by 1%. It is also inferred from the above study that
most of the mobile phone owners used it for chatting
with friends rather than using it for maintaining
contact with their parents which is most of the time
the reason for mobile provision. As far as the validity
of the study is concerned, it has certain limitations.
The colleges, in which the study was carried out, are
not the true representatives of whole of the student's
community. The results are very specific and can be
generalized only on the population with same
characteristics. Study included only the institutions
with female students so the results of the study
cannot be applied on institutions
Our study reinforces the belief of previous studies
that college students are tremendous users of mobile
phone and majority of them (85.5%) own a mobile.
Most probable reasons for acquiring a cell phone are
personal safety, parental contact, social interaction,
time management and they might feel left out socially
without it as trendy mobiles have become a fashion
and symbol of status. Majority of the students were
found to use their mobile quite reasonably in terms of
monthly expenditure and time spent on mobile
phone. This finding is consistent with other studies
Table-8: Frequency of mobile phone contact
with parents.
Contact with parents
15
Frequency(%age)
Not at all
192 (57.8)
> 1/day
46 (13.9)
Once per day
37 (11.1)
Weekly
15 (4.5)
Monthly
2 (0.6)
Esculapio - Volume 07, Issue 04, October-December 2011
with co-education and male students whose trends of
mobile phone usage could be different.
friends through messaging and their expenditure and
time spent on phone was reasonable. Few of the girls
were using mobile to contact their parents.
Conclusion
Department of Community Medicine
Fatima Jinnah Medical College, Lahore
The above research depicted extensive use of mobile
phone among female college students. Majority of the
students were not using mobile phone during the
class. The students used mobile to chat with their
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
References
1. Kay HB. Cellular telephone use. A
survey of college business
student. J Coll Teach Learn
2008;5(4):55-62 .
2. S h e e r e n N. Z o l ke f l y a n d
Rozumah Baharudin, University
of Putra, Malaysia.
3. Nasar J, Hecht P, Wener R. Call if
you have trouble: mobile phone
and safety among students. Int J
Urban Region Res 2007;
31(4):863-73.
4. Chakraborty S. Mobile phone
usage patterns amongst university students: a comparative study
between India and USA. M.S.
thesis submitted to University of
of mobile phone technology.
ANZMAC 2005 Conference
Electronic Marketing, 87-96.
8. Niaz U. Addiction with internet
and mobile: an overview. J Pak
Psychiatr Soc.2008;5(2):72-80.
9. Ito M, Okabe D. Technosocial
situations: emergent structuring
of mobile email use. In M Ito,
Okabe D, Matsuda M (eds).
Personal portable pedestrian:
mobile phones in Japanese life;
Cambridge: MIT Press:p 257-73.
10. M Metrics. Organization of
research and statistical analysis.
Co
py
Ri
gh
ts
@
Es
cu
lap
io.
pk
North Carolina at Chapel Hill.
2006.
5. Taylor AS, Harper R. Talking
activity: young people and mobile
phones. Presented at CHI 2001
Workshop: mobile communications: understanding users,
adoption & design, 1-2 April,
2001.
6. Watson, M., Mobile healthcare
applications : a study of access
control. North, (c), 2006;6-9.
Available at: http://portal.
acm.org/citation.cfm?id=150152
4.
7. James, D., & Drennan, J.
Exploring addictive consumption
16
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
ANTI-HYPERGLYCEMIC Effect of Aloe Vera Leaf Gel
Extract in Alloxan Induced Diabetic Rabbits
Sajida Malik, Zahid Qamar, Samina Kareem, Javed Khalil and Naveed Iqbal Ansari
Objective: To evaluate the anti-diabetic activity of aloe vera ethanolic extract in alloxan induced
hyperglycemic rabbits as an alternate mode of treatment for type-2 diabetes.
Methods: In the present experiment sixty six healthy male rabbits of local strain weighing 1.0-1.7
@
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kg were divided into 3 groups. They were injected intravenously with alloxan monohydrate
according to body weight to induce diabetes. Baseline normal blood sugar level of all the rabbits
was recorded. The rabbits turned diabetic within 1-2 weeks after injection of alloxan. A BSR level
of = 250 mg/ dl was criterion for diabetes. Group A, served as control and was treated with placebo
(5 ml of distilled water daily). Group B was treated with Metformin (135 mg/ kg body weight daily)
and Group C was treated with ethanolic extract of aloe vera (300 mg/ kg body weight daily). Blood
sugar levels were recorded as 0hrs, 2hrs and 4hrs readings on days 1, 14 and 28 of the treatment.
The data was recorded in specially designed proforma and analyzed with the help of computer
software SPSS version 16.
Results: There was no significant change in the BSL in Group A (the control group, diabetic
rabbits treated with 5 ml/ day of distilled water). Overall, in a period of 28 days, there was 44.1%
reduction of mean BSL in Metformin group and 25.3% reduction of mean BSL in Aloe Vera group.
Conclusion: The ethanolic extract of Aloe Vera leaf gel exhibited anti-diabetic activity in alloxan
induced diabetic rabbits. Although antihyperglycaemic effect of Aloe Vera gel extract is lesser
than that of Metformin but it has a gradual and sustained pattern.
Keywords: Aloe Vera, Diabetes mellitus, Rabbits and Alloxan monohydrate.
Introduction
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Diabetes mellitus is a multi-factorial disease that has a
significant impact on health, quality of life and life
expectancy of the patients, as well as on health care system.
Worldwide, the number of patients is assumed to be
1
doubled in thirteen years from 1997 to 2010. It remains an
important risk factor for cardiovascular disease and
increasing rate of childhood and adult obesity. Diabetes is
likely to become even more prevalent over the coming
decade. Diabetes is commonly associated with premature
mortality, predominantly due to atherosclerotic vascular
disease.2 The microvascular complications, whichaffect the
small blood vessels in the eye, kidney and nerves, are
associated with considerable morbidity. The economic and
social costs of diabetes are enormous, both for health care
services and through loss of productivity. In developed
countries, 10% or more of the total health budget is spent
on the management of diabetes and its complications.3 For
type-2 diabetes, treatment begins with a nutritionist
designed diet control plan, exercise and weight reduction.
Oral hypoglycemic agents are used if these measures fail.
Later on, insulin may also be required due to beta cell
failure.
The synthetic oral hypoglycemic agents have a number of
side effects like gastrointestinal, cutaneous, hepatic and
4
renal. They also have teratogenic effects. . Hence many
studies were carried out to investigate the hypoglycemic
effect of some plants used traditionally to treat diabetes
beside identification of active ingredients, mode of action
and safety. Herbal extracts have been confirmed for its
hypoglycemic effect in human and animals for type-2
diabetes.5
Aloe species are perennial plants, belonging to the family
Liliaceae. These are native to North Africa and cultivated in
warm climate areas. The plant is the source of two herbal
preparations, latex and Aloe gel which is often called Aloe
6
Vera. The gel is composed of mannose-phosphate,
acetylated mannan, glucomannans, alprogenglucoprotein
and glucosylchromone. Aloe Vera has been used in folk
medicine as a remedy for various diseases. However there
have been controversial reports on the hypoglycemic
activity of Aloe species.7 The present study was conducted
to evaluate the effect of Aloe Vera ethanolic extract on
blood glucose level and to compare with that of metformin
in alloxan induced diabetic rabbits.
Material & Methods
The present research was carried out in the
department of pharmacology Services Institute of
Medical Sciences/ P.G.M.I. Lahore from February to
July 2010. A prior approval of the study was obtained
from the ethical committee of the PGMI Lahore.
The Experimental Animals
Healthy male rabbits of local strain weighing 100017
Esculapio - Volume 07, Issue 04, October-December 2011
Department of Plant Pathology, University of the
Punjab Lahore. Fresh healthy leaves of Aloe Vera,
0.5-0.75 meter in length, were washed with water to
remove all the mud and dust particles. The leaves were
cut in longitudinal sections carefully to remove the
outer hard rind (the skin) and to obtain the colourless
transparent gel. The mucilaginous pulp of Aloe Vera
leaves was homogenized in a specialized chamber
called column. The resultant colourless homogenous
fluid was centrifuged at 4000 revolutions /min for a
period of 15 minutes and then filtrated to remove the
fibres. The colourless filtrate was mixed with 95%
ethanol in 1:1 ratio to extract the active ingredients of
the gel. The mixture was collected and processed in a
rotary evaporator to remove the water content. The
resultant solid component was kept in the freeze drier
to produce absolute dryness The end product was in
the form of greyish white powder which was
collected in amber coloured air-tight glass bottles to
avoid light and moisture. The powder was stored at
room temperature and a known amount of distilled
water was added to make suspension in the required
dose before administration.
Determination of dosage
The dose of Aloe Vera gel extract was determined on
body weight basis. The required dose in our study was
300 mg/kg body weight/day as a single daily dose
before meals. The dose was determined according to
Rajeshkaran who used Aloe Vera extract in rats to
11
study effects on serum lipids. Metformin was given
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1700 g were purchased from the veterinary research
centre Lahore. The rabbits were kept in the animal
house of PGMI Lahore one week prior to the
commencement of the study for observation and
acclimatization of the animals to the new
environment. The animals were fed on green fodder,
grains, cereals and plentiful of fresh water. The
animals were kept in separate cages.
Induction of Diabetes in Rabbits
The induction of diabetes in experimental rabbits was
done by injecting alloxan monohydrate solution
8
intravenously (in the marginal ear vein). The dose of
alloxan monohydrate/kg body weight was calculated
9
according to that mentioned by Puri D et al.
Immediately prior to injection of alloxan, 2 grams of
glucose/kg body weight dissolved in 10 ml water was
administered orally to each rabbit to counteract any
expected hypoglycaemia. The required dose was
dissolved in 8 ml water and injected in the marginal
ear vein of the rabbit using 27 gauge needle and 10 ml
10
syringe.
Eight days after the administration of alloxan, the
surviving rabbits (66 in number) of BSR = 250 mg/ dl
were taken as diabetic and kept for further study. In
case of animal found non-diabetic, a low dose
repetition was made at an interval of 5-10 days each.
For example a rabbit previously given 75 mg/kg was
given 55 mg/kg the second time and 30 mg/kg the
third time if required. Most of the animals became
diabetic after a second dose. The rabbits which died
after alloxan injection, due to hypoglycaemia, were
excluded from the study.
The rabbits were divided in three groups as under.
Group-A (Control)
Twenty two alloxan induced diabetic rabbits treated
with placebo (5 ml of distilled water/day).
Group-B (Standard)
Twenty two alloxan induced diabetic rabbits treated
with Metformin (135 mg/ kg body weight/day).
Group-C (Test)
Twenty two alloxan induced diabetic rabbits treated
with Aloe Vera extract (300 mg/ kg body weight/
day).
The Plant Material
There are more than 300 species of aloe vera. Aloe
Barbadensis Miller is the true aloe which is used in the
study (Fig.-1). 100 kg of fresh, mature and healthy
leaves of Aloe Vera were purchased from nurseries of
Tehsil Pattoki, Distt. Kasoor.
Preparation of Aloe Vera Ethanolic Extract
The ethanolic extract of Aloe Vera was then prepared
with collaboration of the Herbal Heritage Centre,
Fig-1: Aloe barbadensis miller.
18
Esculapio - Volume 07, Issue 04, October-December 2011
Results
in the dose of 135 mg/kg body weight/day according
To Sirtori et al, who used Metformin in rabbits to
12
study its effects on atherosclerosis. Metformin
powder is not available in Pakistan. Therefore, tablets
Glucophage 250 mg containing 250 mg of
metformin BP as active ingredient were purchased
and finely crushed with help of mortar and pestle to
obtain the powder. The powder obtained from 250
mg tablet was then mixed with 10 ml of distilled
water. The resultant suspension contained 25 mg of
active ingredient of metformin in each ml. The dose
in ml was calculated according to the body weight. For
example, a rabbit of 1.2 kg required 6.5 ml of
suspension. At the time of administration, the
suspension was well shaken. A feeding tube (8 Fr) was
passed down into the rabbit stomach. Then the
desired drug was dissolved in 10 ml of distilled water
and administered with the help of disposable 10 cc
syringe via the feeding tube. The drugs were
administered as single daily dose.13
Blood Sample collection
The blood sample, 2 ml each time when required, was
14
drawn as described by Akhter et al in 1982 according
to following technique. The rabbit's ear was dabbed
with xylene solution so that the marginal ear vein
became prominent. The sample was collected using a
5 ml disposable syringe. The samples were then
centrifuged to obtain the sera which then were
subjected to further glucose level testing (Fig.2).
A baseline BSR of all the rabbits was recorded before
induction with alloxan. The weight of each rabbit was
also recorded. The drugs (aloe extract, Metformin
and distilled water in respective groups) were
administered as single daily dose in the morning. BSL
was also recorded before administration of drugs (0
hrs reading). The animals were then fed and two more
readings recorded according to the schedule (2 hrs
and 4 hrs). The data was recorded in specially
designed proforma. Blood glucose levels were
determined by the glucose oxidase peroxidase
method which is specific for glucose, as it responds
only to it.
Statistical analysis
All grouped data were evaluated statistically with
SPSS version 16 software. Hypothesis testing
methods included one-way analysis of variance
(ANOVA) followed by Post hoc Tukey test of
15
multiple comparisons. p < 0.05 was considered
significant. All the numerical values were represented
as mean ± SD. Means of blood sugar levels of all the
groups were compared on days 1, 14 and 28 of the
study independently.
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The data of BSL of control (Group-A) and drugs
treated groups (B & C) on Day-1 of the treatment are
shown in Table-1. The 0 hour readings on Day-1
depict the pre-treatment values of all groups. These
values were 291.2 ± 21.8, 283.0 ±15.3 and 288.3 ±
19.4 in groups A, B and C respectively. There were no
statistically significant differences in these values
(p=0.351).
The mean BSL readings at 2 hour after administration
of the respective drugs were 291.7 ± 21.9 in GroupA, 243.6 ± 22.0 in Group-B and 277.5 ± 19.5 in
Group-C respectively. The mean BSL remained
almost the same in control Group-A. There was
12.7% reduction of mean BSL in Metformin group
and 3.81% reduction of mean BSL in Aloe vera
group.
Co
Fig.-2: Blood sample collection.
The mean BSL readings at 4 hour were 290.409 ± 23.1
in Group-A, 186.6 ± 17.3 in Group-B and 271.3 ±
17.2 in Group-C respectively. Again, there was no
change in mean BSL of control Group-A as
compared to starting level. The reduction in mean
BSL at 4 hours as compared to starting levels in
Metformin and Aloe Vera groups were 32.62% and
5.90% respectively. On Day-14 (Table-2), the analysis
of results within groups showed no significant
change in Group-A, at 2 hours as compared to 0
hours readings (p=0.949). The changes were
19
Esculapio - Volume 07, Issue 04, October-December 2011
Insignificant in Group-B (p=0.105) and Group-C
(p=0.391). At 4 hours level, again there were
insignificant differences within group analysis of the
results in Group-A (p=0.946). This difference was
significant in Group-B (p=0.013) and not significant
in Group-C (p=0.148).
Upon inter-group analysis of the results, there was
highly significant lowering of mean BSL in groups B
& C, as compared to Group-A, both at 2 hours and 4
hours level. On comparing Metformin group with
Aloe Vera group, the blood sugar lowering effect was
more in Metformin group (p< 0.005).
On Day-28 (Table-3), the analysis of results within
groups showed no significant change in Group-A at 2
hours level as compared to 0 hours readings
(p=0.932). Similarly, the changes were insignificant in
Group-B (p=0.528) and Group-C (p=0.931). At 4
hours level, again there were insignificant differences
within group analysis of the results of all groups.
Upon inter-group analysis of the results, there were
highly significant lowering of mean BSL in groups B
& C as compared with Group-A both at 2 hours and 4
hours level (p<0.005). On comparing Metformin
group with Aloe Vera group, the blood sugar lowering
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effect was more in Metformin group (p< 0.005). On
28th day of the experiment, there was 44.16%
reduction in the mean BSL of metformin group and
25.34% reduction in the mean BSL of aloe vera group
as compared to pre- treatment values on Day-1.
Fig-3 shows the overall effects of control, metformin
and aloe vera on BSL of alloxan induced diabetic
rabbits in their respective groups. There was almost
no response in the control group and the curve is
more or less straight (Blue curve). The response in
Metformin group was rapid in onset on the Day-1 and
then there was a steady decrease in the mean BSL
towards the end (Pink curve). In the Aloe Vera group,
the response was gradual. The maximum response
was achieved in the second week and then there was a
Steady and minimal response in the following days
(Green curve).
Discussion
Es
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Due to modernization of lifestyle, non-insulin
dependent diabetes mellitus is becoming a major
16
health problem in developing countries. The
treatment options have their own drawbacks, ranging
from developing of resistance and adverse effects to
Table-1: Mean blood glucose levels in mg/ dl ± SD on day-1 of treatment.
Time
GP-A
0-HRS Mean±SD
291.2±21.8
2-HRS Mean±SD
P-value
GP-C
283.0±15.3
288.3±19.4
0.456
291.7±21.9
243.6±22.0
277.5±20.6
0.009
4-HRS Mean±SD
290.4±23.1
186.622.017.7
271.1±19.5
0.006
p-value within group
0.997
0.000
0.5
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GP-B
Table-2: Mean blood glucose levels in mg/ dl ± SD on day-14 of treatment.
Time
P-value
GP-B
GP-C
288.1±24.5
175.1±11.7
235.4±15.3
0.00
290.1±20.3
168.1±11.5
230.7±12.9
0.00
4-HRS Mean±SD
286.4±19.6
165.2±10.3
228.2±14.5
0.00
p-value within group
0.949
0.013
0.148
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GP-A
2-HRS Mean±SD
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0-HRS Mean±SD
Table-3: Mean blood glucose levels in mg/ dl ± SD on day-28 of treatment.
P-value
Time
GP-A
GP-B
GP-C
0-HRS Mean±SD
289.4±20.2
164.2±9.4
221.0±11.8
0.00
2-HRS Mean±SD
291.8±23.5
161.1±8.3
218.0±113.0
0.00
4-HRS Mean±SD
288.9±22.0
158.8±10.4
215.1±11.0
0.00
p-value within group
0.997
0.149
0.240
20
Esculapio - Volume 07, Issue 04, October-December 2011
Lack of responsiveness in large segment of patients
17
population As an alternate option, plants provide a
potential source of hypoglycemic drugs and are
widely used in several traditional systems of medicine
to control diabetes. The effects of these plants may
delay the development of diabetic complications and
correct the metabolic abnormalities using variety of
mechanisms.
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200
Day-28
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Day-1
increasing glucose transport across the cell
membrane.20 Because our results showed that
Metformin reduced blood glucose levels in diabetic
animals, the state of diabetes in the animals used in
the present study was not severe. The β-cell damage
was partial because alloxan was carefully administered
with relatively lower dose. The hypoglycemic effect
of plant extracts is generally dependent upon the
21
degree of β-cell destruction. Aloe Vera gel extract
reduced BSR levels in our study. This fact further
proves that the β-cell damage was partial.
The administration of 300 mg/kg body weight of
Aloe Vera leaf gel in the form of ethanolic extract
produced significant BSL lowering effect in alloxan
induced diabetic rabbits throughout the 4 week
observation period. The reduction in mean BSL on
Day-1 was 5.9% and 32.6% in Aloe Vera and
Metformin groups respectively. These results show
that response on first day of treatment was more
abrupt and potent in metformin group as compared
to the Aloe Vera group. In the following weeks, there
was a sustained anti-hyperglycemic effect in both the
Aloe Vera and Metformin groups as compared to the
th
placebo group. On 14 day of treatment, the
percentage lowering of mean BSL was 16.05% and
38.16% in the aloe vera and metformin groups
respectively. These values show that there was
significant response in Aloe Vera group at two weeks
of the treatment as far as the blood sugar lowering
effect was concerned. On 28th day of treatment, the
percentage lowering of mean BSL was 25.3% and
44.1% in the Aloe Vera and metformin groups
respectively. These values, though lower than those
on Day-14, were not remarkably reduced. These
results show that the response with Aloe Vera
treatment was achieved over a period of two weeks
and after that, it remained sustained in the following
weeks. The aforementioned results reveal that both
Aloe Vera and metformin have a significant blood
sugar lowering effect as compared to placebo in
alloxan induced diabetic rabbits. These drugs,
however, showed different patterns of hypoglycemic
action. The onset of action was slightly delayed in
Aloe Vera group as compared to the metformin
group. Moreover, the anti-hyperglycemic effect of
Aloe Vera leaf gel extract is observed to be lesser than
that of metformin in alloxan induced diabetic rabbits.
The BSL lowering effect remained 25.7% in the
present study. Some of the studies explored the blood
sugar lowering effects of various herbs. Kerella
(Memordica Charantia) in a 3 months study reduced
the fasting glucose from 151.2 to 143.8 which were
Fig-3: Effect of placebo, metformin and aloe vera
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on BSL of alloxan induced diabetic rabbits in 4 weeks
time
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During the past few years many phyto-constituents
responsible for anti-diabetic effects have been
18
isolated from plants. The various plants tested for
their anti-diabetic activity include Aloe Vera, bitter
melon, cinnamon, fenugreek, Asian ginseng,
American ginseng, gurmar, milk thistle, nopal and
chia. In the past 15 years, there have been
controversial reports on the hypoglycaemic activity
of Aloe Vera species, probably due to differences in
the parts of the plant used or to the model of diabetes
chosen.19 So far, the oral hypoglycemic evaluation of
Aloe Vera in the form of ethanolic extract has never
been done in Pakistan and not substantially even
world-wide and that justifies scope of present study.
Metformin is a hypoglycemic drug effective in the
treatment of Type-2 diabetes. Although metformin
increases insulin binding in various cell types, this
effect is not universal and does not correlate with
stimulation of glucose utilization. In contrast, direct
effects of the drug on the glucose-transport system
have been demonstrated. Metformin elevates the
uptake of non-metabolizable analogues of glucose in
both non-diabetic rat adipocytes and diabetic mouse
muscle. In the latter, the stimulatory effect of the
drug is additive to that of insulin. Thus, it is suggested
that the basis for the hypoglycemic effect of this
biguanide is probably at the level of skeletal muscle by
21
Esculapio - Volume 07, Issue 04, October-December 2011
22
Not significant. Cinnamon reduced fasting glucose
23
by 10.3% compared to 3.4% in the placebo group.
Feenugreek reduced mean fasting BSL from 151 to
112 mg/dl after 6 months.24 Gymnema Sylvestre
(gurmar) was evaluated in diabetic patients. 22 type 2
diabetic patients on sulfonylurea treatment took 400
mg daily for 18-20 months. Average fasting glucose
decreased from a baseline of 174 to 124 mg/dl after
25
18-20 months. It is evident that all of these plants
exhibited a relatively lesser blood glucose lowering
effect as compared to Aloe Vera gel used in the
present study.
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lowering effect but the animals did not turn
euglycemic. A combination therapy of aloe vera with
oral hypoglycemic agents may reduce the required
dose of these agents. Moreover, the preparation of
ethanolic extract has not been cost effective. The
Aloe Vera leaf gel fresh juice is bitter in taste. Some
forms of additives to make it palatable may be used
rather than the extract to minimize the cost. Due to its
anti-hyperglycemic potential and suspected ability to
reduce oxidative stress, Aloe Vera holds promise.
Department of Pharmacology
SIMS/Services Hospital, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
Conclusion
lap
Aloe Vera leaf gel extract did exhibit some sugar
References
Okyar AA, Car N, Akev G,
Sutherpinar N. Effect of Aloe
Vera leaves on blood glucose levels
in type-1 and type-2 diabetic rat
models. Phytother Res 2001; 15:
157-161.
8. Akhter MS, Ather MA, Yaqoob.
Effect of mamordica charantia on
blood glucose levels of normal
and alloxan induced diabetic
rabbits. Planta Med 1982;32:1035.
9. Saadia SA, Khan AH, Sirhindi GA,
Khan SU. Alloxan induced
diabetes in rabbits. Pak J
Pharmacol 2005; 22, (2): 41-5.
10. Puri D, Prabhu KM, Murthy PS.
Mechanism of action of a
hypoglycemic principle isolated in
fenugreek seeds. Ind J Physiol
Pharmacol 2002; 46.
11. Rajasekaran S, Sivagnanam K,
Ravi K, Subramanian S. Beneficial
effects of aloe vera leaf gel extract
on lipid profile status in rats with
streptozotocin diabetes. Clin
Exper Pharmacol Physiol 2006;
33, (3): 232.
12. Sirtori CR, Catapano A, Ghiselli
G C. M e t f o r m i n : A n a n t i
atherosclerotic agent modifying
very low density lipoproteins in
rabbits. J Atheroscleros 1977; 26
(1): 79-89.
13. S a a d i a S A . H y p o g l y c e m i c
ts
gh
py
Co
14.
@
Es
cu
7.
Ri
1. Amos AF, Mcarty DJ, Zimmet P.
The rising global burden of
diabetes and its complications:
estimates and projections to the
year 2010. Diabet Med 1997;
14(5): 81-5.
2. World Health Organization/
International Diabetes Federation. The Economics of
Diabetes and Diabetes care: a
report of the Diabetes Health
Economics Study Group.
Geneva: WHO/IDF. 1999.
3. Jonsson B. Revealing the cost of
type II diabetes in Europe.
Diabetologia 2002; 45:5-12.
4. Richard JM, Michael LA. Type 2
diabetes mellitus: update on
diagnosis, pathophysiology and
treatment. J Clin Endocrinol
Metabol 1999; 84 (4):1165-71.
5. Shanmagasundram ER, Gopinath KL, Radha SK, Rajendran
VM. Possible regeneration of
islets of Langerhans in streptozotocin diabetic rats given
Gymnema Sylvestre leaf extracts.
J Ethnopharm 1990; 30: 265-79.
6. A n g - L e e M K , B a r s i l a D.
Commonly used herbal medicines. In Chung SU, Bieber EJ
Bauer BA. (Eds) Text Book of
Complementary and Alternate
Medicine 2006; 2nd ed. CPI Bath
UK: 13.
22
15.
16.
17.
18.
19.
20.
evaluation of Panax Ginseng
(radix Rubra) in normal &
alloxan induced diabetic rabbits
(M. Phil. Thesis) University of
Punjab 2005; 56-72.
Brown AM. A new software for
carrying out one way ANOVA
post hoc tests. Computer
Methods and Programs in
Biomedicine 2005; 79, (1): 89-95.
Jarald E, Joshi SB, Jain DC.
Diabetes and herbal medicines.
IJPT 2008; 7: 97-106.
Derek LR. Current therapeutics
algorithms for Type-2 diabetes.
Diabetes 2001; 4: 38-39.
Kesari AN, Kesari S, Santosh
KS, Rajesh KG, Geeta W. Studies
on the glycemic and lipidemic
effect of Murraya Koenigii in
experimental animals. J Ethno
Pharmacol 2007; 112 (2):305-11.
M. Collins and J. R. McFarlane.
An exploratory study into the
effectiveness of a combination
of traditional chinese herbs in the
management of type-2 diabetes.
Diabetes Care 2006; 29(4): 945-6.
Bennete PN, Brown MJ.
Diabetes mellitus, insulin, oral
anti-diabetes agents, obesity. In
Clinical Pharmacology; Churchill
Livingstone 2005 9th ed. 679698.
Kedar P, Chakrabarti CH.
Esculapio - Volume 07, Issue 04, October-December 2011
of bittergourd seed and
glibenclamide in streptozotocin
induced diabetes mellitus. Ind J
Exp Biol 1982; 20: 2325.
21. Dans AML, Villarruz MVC,
Jimeno CA. The effect of
Memordica Charactia capsule
preparation on glycemic control
in Type-2 diabetes mellitus needs
further studies. J Clin Epidemiol
2007; 60: 554-559.
22. Mang B, Wolters M, Schmitt B.
Effects of Cinnamon extract on
plasma glucose. HbA1c, and
serum lipids in diabetes mellitus
Type-2. Eur J Clin Invest 2006; 36:
340-344.
23. Sharma RD, Sarkar A, Hazra DK.
Use of fenugreek seed powder in
the management of non-insulin
dependent diabetes mellitus.
Nutr Res 1996; 16: 1331-9.
24. Baskaran K, Kizar B, Ahamath
K. Anti-diabetic effect of a leaf
extract from Gymnema sylvestre
in non- insulin dependent
diabetes mellitus patients. J
Ethno Pharmacol 1990; 30: 295306.
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Answer Picture Quiz
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This man shows dark pigmentation and severe bone marrow suppression resulting in leucopenia and
thrombocytopenia. On detailed investigations it was found that he took Isotab tablet (ISDN) which was
contaminated with toxic dose of pyrimethamine, an anti folate drug used for malaria prophylaxis.
Pyrimethamine can cause skin pigmentation and bone marrow suppression. Treatment consists of early
diagnosis, withdrawal of offending agent and folinic acid.
23
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Diabetes Awareness - Knowledge Attitude and Practice Of
Diabetic Patients In A Tertiary Care Setting
Ahmad R, Younis BB, Masood M and Noor W.
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Objective: To assess the awareness of people regarding diabetes and their practices about the
disease so that a comprehensive education program may be designed to give awareness to the
diabetic patients and contribute towards reduction of the complications of the disease.
Material & Methods: A cross sectional study which included 714 patients with known type 2
diabetes conducted in Shalimar Hospital, Lahore. The technique used was non probability
purposive sampling. A simple questionnaire was distributed in the diabetic clinic and a diabetic
nurse filled the questionnaire by asking questions from the patients.
Results: Mean age was 50.5+24.11 years. There were 25.5% males and 74.5% females. A large
number (37.2%) were uneducated and only 16.1 % had education above grade 10. Regarding the
economic status, 62.9% fell into grade 1 economic status and 12.9% in grade 4. In the study
64.1% of the patients thought that the disease had no cure. 84.8% of the patients were of the
opinion that the disease and the medication would decrease with time. Only 35% patients knew
that it may affect different organs of the body irreversibly. 69% of the patients did not walk at all.
Conclusion: In a tertiary setup in Lahore, one of the most prosperous cities of Pakistan, the
awareness level is quite poor even amongst the people who are suffering from diabetes. The
overall education level in our patient group is also very poor. If the awareness level of diabetic
patients remains as it is today, many new faces of diabetic complications will unveil each year.
There is a need for an effective disease management program in the country.
Keywords: Diabetes Mellitus, Health education, KAP, Awareness
Introduction
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The prevalence of diabetes has risen more rapidly in
1
South Asia than in any other part of the world. Its
prevalence in Pakistan in the age group 20-79 years is
6.2 million2 i.e. more than 10% of the population.
Pakistan has the 7th largest population of diabetes in
th
the world and will take 4 place in year 2025. Deaths
from diabetes alone are projected to increase by 51%
3
over the next ten years. According to Diabetic
Association of Pakistan study into chronic
complications involving 500 people with diabetes,
retinopathies affected 43% of the people,
nephropathy affected 20% and neuropathy affected
4
40% of the people. The worldwide prevalence of
diabetes has risen dramatically in the developing
countries over the past two decades.5 The economic
burden of diabetes is extremely high for the
governments and the individuals suffering from
diabetes. There is an urgent need of effective disease
management program in the country. Diabetes
related complications may be prevented if good
metabolic control is achieved.6-8 Diabetic patients
develop complications due to poor awareness
regarding the disease and inadequate glycemic
9
control. A study done in Australia showed that
24
among immigrants with diabetes from developing
countries, high proportions were unaware of their
disease. Unawareness was associated with poorer
10
control of diabetic retinopathy risk factors. A study
from India also showed that the majority of the
patients are ignorant about their chronic disease. It
was shown that even though 94.4% of diabetic
patients knew that they had diabetes, still 52.7% of
them stopped medication on their own.11
It is recommended by the American Diabetic
Association and the American Academy of
Ophthalmology that a dilated eye examination be
performed on patients with diabetes mellitus during
an initial assessment and at least annually thereafter.
But the fact was one of every four surveyed patients
with diabetes mellitus in west Virginia who did not
receive an annual dilated eye examination was not
12
aware of the need to do so.
We did this study to investigate the awareness level
and attitude of type 2 diabetes patients which may
guide us to formulate a comprehensive awareness
program which may be delivered in the hospital to all
those who attend the hospital diabetic clinic and to
make the people aware about the disease and its
complications through the outreach programs.
Esculapio - Volume 07, Issue 04, October-December 2011
Material & Methods
This cross sectional study included 714 patients with
known diabetes type 2. The technique used was non
probability purposive sampling. A simple
questionnaire was distributed in the diabetic clinic
and a diabetic nurse filled the questionnaire by asking
questions from the patients. All these patients
attended the diabetic clinic of Shalimar Hospital,
Lahore, a tertiary care teaching hospital attached to
Shalimar Medical and Dental College.
, 0%
182, 25%
Table-1: Frequency distribution of education level of the
subjects.
female
Education Level
Frequency
No education
266
37.2
183
25.6
150
21.0
Beyond matric
115
16.1
Total
714
100.0
Primary
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Matric
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Male
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532, 75%
Fig-1: Frequency distribution of gender.
Percentage
Table-2: Frequency distribution of social status of the
@
Results
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regarding their disease was also different. 16.1 % of
the diabetic patients were of the idea that their disease
could be completely cured and 19.6 % of the diabetics
did not know whether it will be cured or not, meaning
thereby that a total of 35.7were completely ignorant
about the nature and course of their disease.
Even more alarming fact which was revealed in our
study was that , 84.8 % of the diabetic thinks that
severity and medication for disease control will be
decreased with time. When we asked about the
occurrence and nature of the effects of the disease 15
% says no effects. 80.5 %
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More females than males attended the diabetic clinic.
This may be due to obesity or because of a sedentary
life style who have an increased risk of getting the
disease.13 A large number i.e. 37.2% had no education
giving an idea about the literacy ratio in Lahore
amongst the diabetic patient presenting at tertiary
care. Certainly this is among the patient living in
capital of most literate province of Pakistan. We may
get an idea of the population literacy at the suburbs
and small towns of Pakistan. 14 These figures of
education status should be taken into account while
preparing a national program of awareness for the
diabetics. We divided the social categories from 1to 4
status according to their asset possession. Social
category 1 is among the highest presenting in the
clinic. It might indicate a link between the disease and
its poor control and economic/ social status.
The percentage of diabetics visiting the clinic for
once or more than once in 1 month time was 90.8 %
showing that either they were not controlled and
needed to visit the clinic very frequently or they were
not guided properly to keep the same medication if
their blood sugar was controlled. Proper training and
guidance may be very helpful for preservation of lot
of resources. The perception of the patients
subjects.
Social Status
Frequency Percentage
House and vehicle owned (1)
450
62.9
Owned house and no vehicle (2)
121
16.9
Rented house and owned vehicle (3)
51
7.1
Rented house and no vehicle (4)
92
12.9
714
100.0
Total
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were of the view that there are some effects but those
were symptoms, in fact, what they were explaining
like weakness and polyuria and body aches. Only 4.3
% of the diabetic patients have precise idea that it may
effect different systems like eye, kidneys and heart.
Only 30.9 % of the diabetic patient in our setting
were involved in any physical activity or walk
including once a week or thrice a week or daily.
Discussion
Diabetes is one of the largest endemic in noncommunicable, non-infectious disease. The
morbidity, mortality and financial cost for treating
diabetes and its complication is enormous. Practically
it is out of scope for the developing countries like
Pakistan and it also poses lot of financial burden on
25
Esculapio - Volume 07, Issue 04, October-December 2011
Table-7: Frequency distribution of Q#5 (Do you walk).
Table-3: Frequency distribution of Q#1(How often do
you consult with doctor?).
Frequency Percentage
549
90.8
After three months
43
6.0
After six months
12
After one year
10
1.4
714
100.0
Total
1.7
Yes
116
16.1
No
458
Total
714
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Total
109
15.2
100.0
py
84.8
Co
No
605
714
Table-6: Frequency distribution of Q # 4 (What do you
know about complexity of diabetes, and does it have any
effects on the organs).
Frequency
Percentage
Has some effect
575
80.5
No effect
108
15.1
Involves more than one systems
31
4.3
Total
714
221
30.9
204
6
11
Looking at our own cross sectional survey, which is
done in the capital of most literate province of
Pakistan and in a tertiary care hospital, we can
observe, that the people who are suffering from this
disease are poorly aware about the progressive and
aggressive nature of diabetes .A very few are aware of
precise complication that it can lead to. Most of the
diabetic patients are not aware of the importance of
the physical activity or at least not doing so.
What we shall plan or do to tame this disease? We
think we need to save our resources and as well as our
population either suffering from diabetes or who are
potential diabetics.
Prevention is the answer. But how simple is that?
Strategies at the primary, tertiary and national level
needs to be designed to make the people in general
and diabetics especially, aware of the course,
complications prevention and treatment of this
disease. However before planning and devising such
awareness programmed we need to investigate the
present prevailing awareness, attitudes and practices
of diabetic population in different regions of
Pakistan. We also need to know the socioeconomic
and literacy level of different areas and customized
strategies need to be adopted. Small and large cross
sectional surveys are needed, and there after their
Meta analyses to make the awareness programs
successful.
lap
100.0
Table-5: Frequency distribution of Q#3 (Is medication
and
. disease decreased with time?).
Yes
Yes
cu
19.6
Percentage
69.0
Conclusion:
64.1
Frequency
493
3 day a week
ts
140
No
1 day a week
gh
Don’t know
100.0
Es
Percentage
714
Daily
@
Frequency
Total
If yes
the individuals as well. The economic burden on the
developed countries like US is also very high.
Taking alone the diabetic foot complication, which is
probably less common than other complication in
this part of the world, the average cost of treating
diabetic foot ulcers from UT G1 to G4 is
enormous.15 If taken into account all the other
complications of diabetes, we may need to divert all
our resources to cover the treatment cost of diabetes
complication alone
Table-4: Frequency distribution of Q#2 (Do you think
diabetes can be fully curable?).
Percentage
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pk
Every month
Frequency
Department of Medicine
Shalamar Hospital, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
100.0
26
Esculapio - Volume 07, Issue 04, October-December 2011
References
1. Ghaffar A, Reddy KS, Singhi M.
Burden of non-communicable
diseases in South Asia. BMJ
2004; 328 ; 807-10.
2. International Diabetes Federation. Diabetes Atlas, Executive
summary. 2nd Belgium IDF;
2003.
3. Basit, A, Williams R. World
Diabetes Day. Promoting care in
underserved communities :
launching World Diabetes Day in
Karachi. 2006; 51(2):46-7.
4. Shera AS, Jawad F, Maqsood A,
Jamal S, Azfar M, Ahmed U.
Prevalence of chronic complications and associated factors in
type 2 diabetes. J Pak Med Assoc
2004 ; 54 ; 54-9.
5. Muninarayana C, Balachandra G,
Hiremath SG, Iyengark, Anil NS.
Prevalence and awareness
regarding diabetes mellitus in
rural Tamaka, Kolar. Int J
Diabetes Dev Countries 2010 Jan
; 30 (1) ; 18-21.
6. Effects of intensive bloodglucose control with metformin
on complications in overweight
patients in type 2 diabetes
(UKPDS34). UK Prospective
Diabetes Study Group Lancet
1998 ; 352; 837-53.
Intensive blood glucose control
with sulphonylureas or insulin as
compared with conventional
treatments & risk of complication
in patients with type 2 diabetes
(UKPDS 33). United Kingdom
Prespective Diabetes Study
(UKDPS) Group Lancet 1998 ;
352 ; 837-53.
8. UKPDS 28: A randomized trial
of efficacy of early addition of
metfor min in sulfonylureatreated type 2 diabetics. UK
prospective Diabetes study group.
Diabetic Care .1998;21: 87-92.
9. Malathy R, Narmadha M, Ramesh
S, Alvin JM, Dinesh BN. Effects
of diabetes counseling program
on knowledge attitude and
practice among diabetic patients in
Erode district of South India. J
Young Pharm. 2011 Jan; 3 (1) 6572.
10. Hueng OS, Tay WT, Tai ES, Wang
JJ, Saw SM, Jeganathan VS et al.
Lack of awareness amongst
community patients with diabetes
and diabetic retinopathy: The
Singapur Malay eye study. Ann
Acad Med Singapore. 2009 Dec;
38 (12) : 1048-55.
11. Beniwal S, Sharma BB, Singh V.
What we can say : Disease
illiteracy. J Assoc Physician India.
2011 Jun; 59: 360-4.
12. Crosby MI, Shuman V. Physician
role in eye care of patients with
diabetes mellitus: are we doing
what we need to?
J Am
Osteopath Assoc. 2011 Feb; 111
(2): 97-101.
13. Younis BB. Ahmad R. Patient
with diabetes mellitus and their
management. A local scenario.
Ann of King Edward Medical
Univ 2010 Oct-Dec;16 (4): 23741.
14. Ulvi OS, Chaudhry RY, Ali T,
Alvi RA, Khan MF, Khan M et al.
Investigating the awareness level
about diabetes mellitus and
associated factors in Tarlai (rural
Islamabad). J Pak Med Assoc
2009 Nov; 59 (11): 798-801.
15. Ali SM, Fareed A, Humail SM,
Basit A, Ahedani MY, Fawwad A
et al. The personal cost of
diabetic foot disease in the
developing world- A study from
Pakistan. Diabet Med. 2008 Oct
;25(10): 1231-3.
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27
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Prevalence of Polycystic Ovarian Disease (PCOD) Among
Female Medical Students
Zulara Wahla, Sadia Mushtaq, Tasneem Fatima Rana, Shezre Anum, Nigat Begum, Farida Rafique,
Ghausia Mahmood Gillani and Tajammal Mustafa
Objective: To estimate the prevalence of PCOD among female medical students.
Material & Methods: A cross sectional study of 1st and 2nd year medical college students was
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undertaken to estimate the prevalence of PCOD. Data was collected through a self-administered
questionnaire based on the clinical tool developed by Pedersen Sue et al. Obesity, longer and/or
abnormal menstrual cycles, hair on upper lip, chin, breast, chest, back, belly, arms, and thighs,
dark hair and acne were associated with the diagnosis of PCOD. Data was analyzed using SPSS
and descriptive statistics were calculated. Chi-square or Fisher exact test were used to determine
statistical significance at α=0.05.
Results: A total of 391 students from 1st (75%) and 2nd (25%) year participated in the survey.
The majority of the students were aged between 18-20 years (96%), originated from Punjab
(79.1%), had less than 50,000 Rupees per month family income (57%) and lived in the hostel
(60%). Although the majority reported having normal menses (79.7%) with an average length of
25-34 days (56.7%), a significant minority reported one of the diagnostic criteria of PCOD
especially fewer than 8 menstrual cycles per year (18.5%), acne (40%) and a coarse body hair
pattern (41.8%). This pattern included coarse hair on the upper lip (20.8%), chin (13.1%), breast
(10.5%), chest (6.7%), back (2.3%), belly (13.8%), arms (10.5%) and thighs (11.8%). A
noteworthy portion also reported other signs and symptoms including being rated as overweight
(25.4%), experiencing milky discharge from nipples (5.4%), suffering from anxiety or depression
(67.9%) and thinning scalp hair (54.9%). Historical indicators included a positive personal history
of ovarian cysts (7.4%) and a family history of diabetes (39%) and ovarian cysts (12.1%).
Conclusion: According to the clinical diagnostic criteria, 7.7% of female medical students in the
sample population have PCOD validating the claim that PCOD is a common and under diagnosed
endocrinopathy and highlighting the need for increased awareness, knowledge and appropriate
treatment.
Keywords: PCOD, Polcystic ovarian disease, Infertility and reproductive health.
Introduction
syndrome vary greatly among women.
The diagnosis of PCOD is based upon the above
symptomatology as well as confirmatory tests. As
history and clinical examination provide a sound basis
for presumptive diagnosis, research utilizing these is
feasible and cost effective. Tests routinely done for
the diagnosis of PCOD are weight, body mass index
(BMI) and abdominal circumference. Laboratory
tests include: hormonal assays (estrogen, FSH, LH,
testosterone), fasting glucose, glucose tolerance, lipid
and prolactin levels. Morphology of the ovaries is
documented through vaginal ultrasound or pelvic
4
laparoscopy .
A 2008 study by The Androgen Excess and PCOS
Society reviewed all of the available data and
interviewed experts in the field. They recommended a
single outline to be used consistently and PCOS to be
defined by the presence of hyperandrogenism
(clinical and/or biochemical), ovarian dysfunction
Co
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Women's reproductive health is an important and
integral part of the medical landscape today. Among
the numerous health issues plaguing women today is
the disorder known as Polycystic Ovarian Disorder.
Many experts contend that PCOD is the most
common female endocrine disorder, affecting
approximately 5-10% of women of reproductive age
(12-45 years old) and is thought to be one of the
leading causes of female infertility. 2
PCOD is a hyperandrogenic disorder associated with
chronic oligo-anovulation and polycystic ovarian
morphology. Altered androgen production and
various metabolic derangements lead to a spectrum
of clinical manifestations which include obesity,
anovulation, amenorrhea, acne, hirsutism, male
pattern baldness, infertility and psychological
impairments including depression and other mood
disorders.3 The symptoms and severity of the
28
Esculapio - Volume 07, Issue 04, October-December 2011
(oligoanovulation and/or polycystic ovaries) and the
11
exclusion of related disorders. Various diagnostic
criteria that exist for PCOD include the National
Institutes of Health, Rotterdam and Androgen
Excess Society criteria. The Rotterdam and AES
prevalence estimates are up to twice as high as those
with NIH criteria thereby demonstrating discrepancies.9 The 1990 NIH criteria was taken as the
standard guideline for diagnosis, however the 2003
Rotterdam consensus workshop revised this criteria
to emphasize that PCOS is a syndrome with no single
diagnostic criteria. Its cardinal features include
hyperandrogenism & polycystic ovarian morphology
and other clinical manifestations include menstrual
irregularities, signs of androgen excess, obesity,
17
insulin resistance and elevated serum LH levels.
PCOD is a significant disease burden which has been
established in the literature, however there is an
inadequate knowledge base among clinicians, medical
students and young females overall, underlined by the
insufficient recent research globally as well as in
Pakistan. The baseline study for PCOS prevalence in
1988 clearly demonstrated that even in women who
considered themselves normal and did not consult
gynecologists, up to 23% had polycystic ovaries
showcasing the insidious nature of this syndrome.22
Subsequent studies have elaborated prevalence rates
globally. A 2000 prospective study in unselected
Caucasian women in Spain reported a prevalence rate
21
of 6.5%. A 2003 study of college students in Seoul
documented a prevalence of 4.9%16 while a 2005
community based screening study in Sri Lanka
utilized an interviewer administered questionnaire
based on the Rotterdam criteria in order to discover a
15
total prevalence of 6.3%. More recently in 2009,
high school students were studied in Rasht, Iran using
multistage cluster sampling based on NIH criteria
which lead to PCOD diagnosis in 11.43%.6 A
prospective cross-sectional 2010 study of Mexican
women reported overall prevalence of 6.0% and
12.8% reported in Mexican-American women.10 The
most recent study in 2011 in Iran established a 7.1%
prevalence using a randomly selected stratified,
multistage probability cluster sampling.5
One of the only relevant and luckily recent studies
done in Pakistan was done to determine the frequency
in obese diabetic and non-diabetic females with
clinical features of hyperandrogenism. The results
demonstrated that the frequency of PCOS was
slightly higher in diabetics than non, 70% versus 61%
respectively. Statistical analysis of these results
demonstrated that there was no significant difference
between the frequencies and therefore this study
negated a very popular view that type 2 diabetes could
be a risk factor of PCOS. However, it is unclear
whether this study will hold up in international
12
research or has even been acknowledged thus far.
This lack of data and understanding of PCOD in
Pakistan clearly dictates the need for further
allocation of funds, attention and research avenues to
this area.
Material & Methods
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A cross sectional study was conducted at Fatima
Jinnah Medical College for Women Lahore. The
study population was based on 1st year and 2nd year
female medical college students. A convenient
sampling technique was used in which all students
who were present in class were included in the study.
It was conducted after a class test of 1st year and an
anatomy stage of 2nd year students in order to
maximize the study population.
Data was collected using a self administered
structured questionnaire based on the clinical tool
developed by Pederson Sue et al.24 A presumptive
diagnosis of PCOD was based on a positive history
of the following signs and symptoms: excessive facial
and hair growth (hirsutism), irregular menstrual
cycles, obesity, acne, male pattern baldness, skin tags,
skin discoloration and personal or family history of
ovarian cysts. The questionnaire sought information
on demographic characteristics such as age, sex,
personal and family history and socioeconomic status
and specific symptoms related to PCOD such as
menstrual cycles, hair growth patterns, family history,
etc.
Previous permission to carry out the study was
obtained from the respective heads of the
departments in which the study took place. Informed
consent was taken from individual students before
the questionnaire was administered. Participation was
entirely voluntary and anonymous.
The variables employed in this study were qualitative
categorical variables which included: presence of
hirsutism, presence of irregular menstrual cycles,
presence of obesity, presence of acne, presence of
male pattern baldness, presence of skin tags, presence
of skin discoloration and presence of personal or
family history of ovarian cysts. Data was analyzed
using Statistical Package for the Social Sciences
(SPSS) software and descriptive statistics were
calculated. Frequency distributions were employed to
analyze the above categorical variables. Chi-square or
Fischer exact test were used to determine statistical
significance at α=0.05.
29
Esculapio - Volume 07, Issue 04, October-December 2011
Results
hair 5.4% reported experiencing a milky discharge
from nipples at some point 40% suffered from
acne.
The study population consisted of 391 students of
1st and 2nd year medical students from Fatima Jinnah
Medical College who were analyzed to determine the
prevalence of PCOD among female medical
students. Data consisting of demographic details and
information regarding the symptomatology of
PCOD among student was considered.
With respect to the demographic characteristics of
the sample population, the majority of the students
studying in Fatima Jinnah Medical College came from
the province of Punjab (78.8%) followed by Kashmir
(7.3%), while the least number of students came from
Balochistan and FATA (4.9%). (Table 1)
The literacy level of most parents was equivalent to
the BA/Bsc level (25%). The majority of mothers
were qualified up to matriculation or BA/Bsc while
the majority of fathers were educated to the MA/Msc
and professional (doctors and engineers) level. None
of the parents were uneducated. (Table 1)
As regards to occupational status, the vast majority of
student's mothers were housewives (70%), while
most of the fathers were doing government jobs
(45%), followed by business (24%). (Table 1)
The majority lived in homes owned by their families
(80%), followed by families living in rental houses
(12%). Only 8% resided in accommodation provided
by the employers and other means (8%). (Table 1)
Most student's families in the study population had an
estimated average monthly income of 15,000 to
39,999 (37%) while the fewest number of parents
earned around 150,000 to 199,999 (2.7%). (Table 1)
The results pertaining to PCOD are as follows:
(Table 2)
Table-1: Selected sociodemographic characteristics of the study population
Background Characteristic
Province of Origin
78.8
Sindh
2.1
io.
pk
Punjab
AJK
Balochistan
1.3
lap
3.6
Other
cu
4.1
Metric
7.9
FA/FSc
15.9
BA/BSc
25.1
MA/MSc
17.7
Doctor/Engineer
16.7
Other postgraduation
11.3
0.3
Es
@
ts
▪
▪
▪
6.2
Below Metric
Uneducated
gh
▪
0.8
Literacy Level of Father
Ri
Literacy level of Mother
The majority (56.7%) had an average menstrual
cycle length of 25-34 days while the remaining had
less than 25 days (22.6%), 35-60 days (5.6%) and
variable length (9.7%).
The vast majority categorized their menstrual cycles as normal (79.7%).
A significant minority reported 8 or fewer
menstrual cycles per year (18.5%).
A coarse body hair pattern was reported by 41.8%
including coarse hair on the upper lip (20.8%),
chin (13.1%), breast (10.5%), chest (6.7%), back
(2.3%), belly (13.8%), arms (10.5%) and thighs
(11.8%).
9.7% reported dark hair on some part of their body and 30.5% skin darkening in some area.
A noteworthy 54.9% complained of thinning scalp
Co
▪
7.3
Khyber Pakhtoon Khawaa
Fata
py
▪
Percentage
Below Metric
18.2
Metric
20.8
FA/FSc
16.2
BA/BSc
22.3
MA/MSc
15.6
Doctor/Engineer
3.6
Other postradauation
2.3
Uneducated
0.1
Father’s Occupation
30
Government Job
44.9
Private Job
16.4
Business
23.3
Other
13.8
Esculapio - Volume 07, Issue 04, October-December 2011
Table-2: Significant characteristics of PCOD
among study participants.
Mother’s Occupation
Housewife
73.3
Government Job
21.3
Private Job
3.6
Business
0.5
Other
1.0
Background Characteristic
Average menstrual cycle length
79.7
Rental
11.5
Employer Provided
6.4
Other
2.1
22.6
25 - 34 Days
56.7
35 - 60 Days
5.6
> 60 Days
1.3
Totally Variable
9.7
Eight or fewer menstrual cycles per year
18.5
Category of menstrual cycle normal
79.7
Categorized as overweight
25.4
Coarse hair pattern on:
lap
Own
<25 Days
io.
pk
Type of Residence
Upper Lip
20.8
Chin
13.1
Breasts
10.5
Belly
13.1
Arms
10.5
Thighs
11.8
Chest
6.7
Back
2.3
Dark Hair on some areas of the body
9.7
Dark skin on some areas of the body
30.5
Thin scalp hair
54.9
Suffer from acne
40.0
Skin tags
7.4
Milky discharge from nipples
5.4
Experience anxiety
67.9
Family history of diabetes mellitus
39.0
Family history of ovarian cysts
12.1
Previous history of ovarian cysts
7.4
@
Es
cu
25.4% categorized themselves as overweight or
obese at some point after puberty Most experienced
some form of anxiety (67.9%) 30.5% suffered from
depression 39% had a positive family history of
Diabetes Mellitus 12.1% had a positive family history
of ovarian cysts 7.4% had a positive personal history
of ovarian cysts Therefore, according to the outlined
diagnostic criteria, 7.7% of female medical students
in the sample population had PCOD. (Table 3)
ts
Discussion
Percentage
Ri
gh
PCOD has been examined all over the world
including studies discussing prevalence in young
females, its association with other comorbid
conditions, diagnostic criteria and treatment.
Unfortunately, very little about this pertinent topic
has been explored in Pakistan.
Co
py
The aim of the study was to assess prevalence of
PCOD in female medical students (1st and 2nd yr)
according to the diagnostic criteria of regularity and
length of menstrual cycles, obesity, acne, hirsutism,
nipple discharge, personal or family history and
psychological impairments. The results exhibit that
although the majority of students report normal
menstrual cycles, a significant minority reported one
of the other diagnostic criteria of PCOD especially
irregular or abnormal menstrual cycles, acne and
coarse hair. The study also validated the claim that
PCOD is a common endocrinopathy as 7.7% of the
study population can be diagnosed according to the
criteria.
Table3: Diagnosis of PCOD among study participants.
Diagnosis of PCOD
The study also took into account the demographic
distribution of the students and literacy level of
31
Percentage
Positive
7.7
Negative
92.3
Esculapio - Volume 07, Issue 04, October-December 2011
students' parents. This clearly showed that majority
of students originate from Punjab which is expected
and logical due to FJMC's location in Punjab. These
results demonstrated that most mothers of students
are housewives who are less educated than the fathers
and the estimated average monthly familial income
falls within 15,000 to 40,000 Rupee range. This is in
accordance with the social distribution of Pakistan's
overall population; however it may be a factor in the
seeming lack of knowledge regarding PCOD and
should be probed further.
The study design had the potential to suffer from a
low response rate due to lack of awareness so in order
to counteract this, a relatively basic questionnaire was
designed. The study design also suffered selection
st
nd
bias as only 1 and 2 year medical students were
included in study population. This bias was mostly
due to time and logistical constraints. In further
studies, this could be eliminated through expansion
of the study population.
The limitations of the study included a short time
frame, very specific study population and lack of
Conclusion
lap
io.
pk
The prevalence of PCOD among female medical
college students using the outlined diagnostic criteria
is 7.7% which is in accordance with the previously
documented and accepted prevalence of 5 to 10%.
This further highlights the need for early and
appropriate treatment in order to avoid or limit the
long term ramifications of PCOD as well as increased
awareness and knowledge of PCOD itself as it is a
pervasive aspect of women's reproductive health.
Department of Community Medicine
Fatima Jinnah Medical College, Lahore
cu
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
Es
References
@
gh
ts
7.
according to NIH criteria. Int J
Fertil Steril 2011;4(4):144-89.
Pasquali R, Stener-Victorin E, O.
Yildiz B, J. Duleba A., Hoeger K;
Mason H et al. Research in
polycystic ovary syndrome today
and tomorrow. Clin Endocrinol
2011;74(4): 424-33.8.
Franceschi R, Gaudino R,
Marcolongo A, Gallo MC, Rossi L,
Antoniazzi F et al. Prevalence of
polycystic ovary syndrome in
young women who had idiopathic
central precocious puberty. Fertil
Steril 2010;93(4):1185-91.
March WA, Moore VM, Willson
KJ, Phillips DI, Norman RJ,
Davies MJ. The prevalence of
polycystic ovary syndrome in a
community sample assessed under
contrasting diagnostic criteria.
Human Reprod 2010 F;25(2):54451.
Moran C, Tena G, Moran S, Ruiz
P, Reyna R, Duque X. Prevalence
of polycystic ovary syndrome and
related disorders in Mexican
women. Gynecol Obstet Invest
2010;69:274-80.
Azziz R, Carmina E, Dewailly D,
Diamanti-Kandarakis E, Escobar-
8.
13.
9.
Co
py
Ri
1. WebMD. Overview of Polycystic
Ovarian Syndrome [homepage
on the Internet]. San Clemente,
California: EMedicine Health;
[April 16, 2010].
2. The Hormone Foundation.
PCOS Overview [homepage on
the Internet]. Chevy Chase,
Mar yland: The Endocrine
Foundation; [2011].
3. PCOS Help Center. Symptoms of
PCOS [homepage on the
Internet].PCOS Help Center;
[2011].
4. PubMed Health. Polycystic Ovary
Syndrome [homepage on the
Inter net]. Bethesda, MD:
A.D.A.M.; [March 3, 2010].
5. Tehrani F, Masoumeh S, Tohidi
M, Farhad H, Azizi F. The
prevalence of polycystic ovary
syndrome in a community
sample of Iranian population:
Iranian PCOS prevalence study.
Reprod Biol Endocrinol. 2011; 9:
39.
6. Asgharnia M, M.D., Mirblook F,
Ahmad Soltani M. The
prevalence of polycystic ovary
syndrome (PCOS) in high school
students in Rasht in 2009
awareness about the subject. However it was a
concerted effort as no proper established work has
been done on this topic in Pakistan. Clearly further
investigation should be carried out in order to
comprehend the scope as well as future disease
progression of PCOD.
11.
12.
32
14.
15.
16.
Morreale HF, Futterweit W et al.
Task force on the phenotype of
the polycystic ovary syndrome of
the androgen excess and PCOS
Society. The Androgen Excess
and PCOS Society criteria for the
polycystic ovary syndrome: the
complete task force report. Fertil
Steril. 2009 Feb;91(2):456-88.
Siraj A, Mushtaq M. Frequency
of polycystic ovarian syndrome
among obese diabetic and non
diabetic females with clinical
features of hyperandrogenism.
Pak Armed Forces Med J 2009;3:
Stankiewicz M, Norman R.
Diagnosis and management of
polycystic ovary syndrome: a
practical guide. Dr ugs
2006;66(7):903-12.
Álvarez-Blasco F, BotellaCarretero J, San Millán J,
Escobar-Morreale H. Prevalence
and characteristics of the
polycystic ovary syndrome in
overweight and obese women.
Arch Intern Med. 2006; 166:
2081-6.
Kumarapeli, R. deA.
Seneviratne, C. N. Wijeyaratne,
R . M . S. C . Ya p a
S. H.
Esculapio - Volume 07, Issue 04, October-December 2011
Dodampahala. A simple screening
approach for assessing
community prevalence and
phenotype of polycystic ovary
syndrome in a semiurban
population in Sri Lanka. Am J
Epidemiol. 2008; 3: 321-328.
17. Byun EK, Kim HJ, Oh JY, Hong
YS, Sung YA. The prevalence of
polycystic ovary syndrome in
college students from Seoul. J
Korean Soc Endocrinol 2005;
20(2): 120-126.
18. Rotterdam E. Revised 2003
consensus on diagnostic criteria
and long-term health risks related
to polycystic ovary syndrome
(PCOS). Hum Reprod. 2004
Jan;19(1):41-7.
19. Kahsar-Miller, Nixon C, Boots
in unselected Caucasian women
from Spain. J Clin Endocrinol
Metabol 2000 Jul;85(7):2434-8.
23. Polson, J, Wadsworth, J, Adams,
S. Franks. Polycystic Ovaries- A
common finding in normal
women. Lancet 1988;331(8590):
870.
24. Timpatanapong P, Rojanasakul
A. Hormonal profiles and
prevalence of polycystic ovary
syndrome in women with acne. J
Dermatol. 1997 Apr;24(4):223-9.
25. Pedersen, Sue. Polycystic ovary
syndrome: Validated questionnaire for use in diagnosis.
Canadian Family Physician 2007;
Vol 53:1041-7.
Co
py
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gh
ts
@
Es
cu
lap
io.
pk
LR, Go RC, Azziz R. Prevalence
of polycystic ovary syndrome
(PCOS) in first-degree relatives of
patients with PCOS. Fertility
Sterility 2001 Jan;75(1):53-8.
20. Peppard H, Marfori J, Iuorno M,
Nestler J. Prevalence of polycystic
ovary syndrome among premenopausal women with type 2
diabetes. Diabetes Care 2001;
24(6) :1050-2.
21. Arefi S. PCOD Prevalence in
adolescents with menstr ual
irregularity. J Reprod Infertil.
2001;2(1):57-62.
22. Asuncion M, Calvo RM, San
Millan JL, Sancho J, Avila S,
Escobar-Morreale HF. A prospective study of the prevalence
of the polycystic ovary syndrome
33
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Anatomical and Functional Results in Macular Hole Surgery
Khalid Waheed, Nasrullah Khan, Saqib Siddique and Muhammad Tayyib
Objective: To assess the anatomical and functional results in macular hole surgery
Material & Methods: This study was conducted in the department of ophthalmology, SIMS/
Es
cu
lap
io.
pk
Services Hospital Lahore over a period of one year between July 2008 to July 2009. Eighteen
eyes of eighteen patients were included in this study. Pars plana vitrectomy was done in all cases.
Internal limiting membrane (ILM) staining with trypan blue or brilliant Perfluoropropane (C3F8)
14% was used in 17 cases and silicone oil was used in one case for internal tamponade. Patients
were advised to posture in face down position for one week. All patients were followed-up for at
least six months.
Results: 18 eyes of 18 patients were operated. 15 (83.33%) patients had idiopathic while 3
(16.66%) had secondary macular holes. There were 17 (94.44%) phakic and 1 (5.55%)
pseudophackic patients. In 5 (27.77%) ILM staining was done with brilliant peel while in 13
(72.22%) patients Trypan blue was used. For internal tamponade C3F8 was used in 17(94.44%)
patients and in 1 (5.55%) silicone oil was used. Postoperatively, 100% macular hole closure was
achieved in all cases with at least 6 month follow-up.
Conclusion: Pars plana vitrectomy with ILM peeling is a very effective technique for the surgical
closure of full thickness macular holes. This technique should be combined with post-operative
head posturing for at least one week to expedite hole closure.
Keywords: Macular hole, Pars plana vitrectomy, internal tamponade.
Introduction
Co
py
Ri
gh
ts
@
Full thickness macular holes are defects involving all
layers of the retina from the internal limiting
membrane through the outer segment of retinal
photoreceptors. The vast majority of macular holes
are idiopathic, and are predominantly seen in
emmetropic patients in the sixth or seventh decades
of life, more often in women at a ratio of 3:1.1,2 The
prevalence of idiopathic macular holes has been
estimated to be 3.3 per 1000.3 Other causes of
macular holes include trauma, high myopia, cystoid
macular edema, inflammation, solar retinopathy,
virteomacular traction syndrome, traction from
epiretinal membranes and degenerative conditions of
the retina.
Material & Methods
This prospective study was carried out in the
Department of Ophthalmology, Services Hospital
Lahore, over a period of one year between July 2008
to July 2009. Eighteen eyes of eighteen patients were
included in this study. After admission, a detailed
history and general, physical and ocular examination
was carried out. Patient's age and gender with
particular reference to any injury or surgery was
recorded. All patients underwent routine examination
including visual acuity testing, pupillary examination,
and slit lamp biomicroscopy. Watzke-Allen test was
performed in every patient and then fundus
photographs were taken. Pars plana vitrectomy was
done in all cases. ILM staining with trypan blue or
brilliant peel was carried out after air fluid exchange.
ILM peeling was carried out with the help of MVR
Blade (Micro Vitreo Retinal) and endgripping
forceps. Perfluoropropane (C3F8) 14% was used in
17 cases and silicone oil was used in one case for
internal tamponade. Patients were advised to posture
in face down position for one week. All patients were
followed-up for at least six months at the interval of
one week, two weeks, one month, two months, and
six months. On each follow up visit, detailed
examination was performed which included fully
corrected distance and near visual acuity and
intraocular pressure. Anterior and posterior segments
were evaluated for any postoperative complications.
Patients data was analyzed using SPSS 10. Relative
descriptive statistics, frequencies and percentages etc.
were computed for presentation of visual outcome
and complications postoperatively. Numeric variables
like age, hospital stay were presented by mean ±
standard deviation. Marginal homogeneity test was
applied with significance taken at p <0.05.
Results
18 eyes of 18 patients were operated. There were 4
(22.22%) males and 14 (77.77%) female patients.
34
Esculapio - Volume 07, Issue 04, October-December 2011
Male to female ratio was 1:3.5; the age of the patients
ranged from 12 to 65 years. 15 (83.33%) patients had
idiopathic while 3 (16.66%) had secondary macular
hole. One patient had macular hole with retinal
detachment (R.D). 14 (77.77%) patients had duration
less than one year. There were 17 (94.44%) phakic and
1 (5.55%) pseudophakic patient. In 5 (27.77%) ILM
staining was done with brilliant peel while in 13
(72.22%) patients Trypan blue was used. For internal
tamponade C3F8 was used in 17 (94.44%) patients
and in 1 (5.55%) silicone oil was used.
Follow Up
Counting Finger
10
2
2 Months
6/60-6/36
8
10
5 Weeks
6/36-6/24
-
3
1 Month
6/18-6/12
-
3
6 Months
lap
Post-Op
cu
Pre-Op
Visual Acuity
io.
pk
Table-1: Pre-op and post-op visual acuity.
for ILM removal includes the contractile
myofibroblasts may proliferate along the ILM causing
tangential traction, and their removal may facilitate
hole closure by eliminating tangential traction. The
process of ILM removal may induce reparative
gliosis, facilitating hole closure.12 ILM peeling was
performed in all our cases. Peeling of the ILM may
achieve successful hole closure with a shorter
duration of face-down positioning.13
Anatomical closure occurred in 17 (94.44%) cases in
13
our study. Sato and Isomae reported a 91% hole
closure rate with ILM peeling, air tamponade, and 1day prone positioning. Possible adverse effects from
ILM removal may include petechial hemorrhages,
retinal whitening, shearing injury to muller cell
12
footplate, transiently depressed focal macular
electroretinogram,paracentral scotoma, & punctuate
inner choroidopathy.14 Petechial haemorrhage
occurred in 7 (38.88%) cases in our study. Peeling of
the ILM is technically difficult without staining,
because of the poor visibility of the ILM and its
friable nature. Indocyanine gree (ICG), infracyanine
15
gree, trypan blue and triamicinolone acetonide have
been used to improve the visibility of the ILM. Of
these ICG has been used most extensively. It
selectively stains the ILM providing excellent
visualization.16 However; several reports suggested
that ICG is toxic to retinal tissue in a dose and time
17
dependent manner. Ho et al demonstrated cytotoxic
effects of ICG on cultured human RPE cells. We used
trypan blue and brilliant peel in our study. Brilliant
peel excellently stained ILM. An improved hole
closure rate has been observed with a long acting gas
tamponade followed by face down positioning at least
90% of the time for 2 weeks. Isomae et al18 noted a
90.5% hole closure rate on prone positioning for
holes of less than 6 months duration. We used 16%
C3F8 in 17 (94.44%) cases with one week face down
position and gained anatomical closure in all cases.
Silicone oil may be used in selected patients who are
unable to maintain face down position postoperatively.19 We used silicone oil in one patient who
had macular hole with RD. Retinal breaks and retinal
detachment (RD) are well known complications of
pars plana vitrectomy. The incidence of retinal
detachment following surgery for full thickness
macular holes ranges from 1.1% to 14%.20 No such
complication occurred in our study. Late reopening
of macular holes secondary toformation of ERMs
21
(epiretinal membranes) has been reported.
Brooks22 noted a 16% of reopening in stage 3 eyes
without ILM peeling, but a 0% incidence in similar
Discussion
gh
ts
@
Es
Idiopathic macular hole (MH) is a rare condition that
affects mainly women in their seventh decade. It has
been proposed that MH develops as a result of
prefoveal cortical vitreous contraction, causing
tangential forces that dehisce the neurosensory retina
4
at the fovea. The role of surgery in macular hole
repair has traditionally been considered to eliminate
tangential surface traction at the vireoretinal interface
and there is clinical, OCT, and surgical evidence to
4-9
support this hypothesis.
Ri
Staging of idiopathic macular hole
Stage 1a ( impending )
py
Normal fovea
Stage 1b (occult)
Stage 4
Complete vitreous
separation
Co
Stage 1a - ( impending holeStage
) 1b - ( occult hole )
Dehiscence
Vitreous contraction with
of photoreceptors
foveal detachment
Stage 3
Seperation of pseudooperculumfromedge
of hole
Stage 2
Seperation of cortex
fromretinal surface to
formpseudo-operculum
Several studies have demonstrated benefit from ILM
10,11
peeling during macular hole surgery. The rationale
35
Esculapio - Volume 07, Issue 04, October-December 2011
eyes where the ILM had been removed. Kumagai et al
also observed a reduction of the rate of reopening of
macular holes from 7% without ILM peeling to 0.6%
with ILM peeling. In out study reopening of macular
hole did not occur in any case. Excellent anatomic and
functional results can be expected in most patients
23
with chronic holes. Stec et al reported an 83% hole
closure rate in holes of longer than 1 year's duration
with vitrectomy, ILM peeling, and long acting gas
tamponade.
promising results for the surgical closure of full
thickness macular holes. Use of vital dyes, Trypan
blue for staining and visualization of the ILM is
pivotal in successful and complete removal of ILM
This technique should be combined with postoperative head posturing for at least one week to
expedite hole closure.
Department of Ophthalmology
SIMS/Services Hospital, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
Conclusion
io.
pk
Pars plana vitrectomy with ILM peeling has very
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cu
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gh
13.
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18.
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Ophthalmol 2002;111:142-9.
Smiddy WE, Feuer W, Cordahi G.
Internal limiting membrane
peeling in macular hole surgery,
Ophthalmol 2001;108:147-6.
Sato Y, Isomae T. Macular hole
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membrane removal, air tamponade, and 1- day prone positioning
Jpn J Ophthalmol 2003;47:503-6
Karacorlu M, Karacorlu S,
Ozdemir H. Iatrogenic punctuate
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Fraser EA, Cheema RA, Roberts
MA. Triamcinolone acetonideassisted peeling of retinal internal
limiting membrane for macular
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Gandorfer A, Messmer EM,
Ulbig MW, Kampik A. Indocyanine green selectively stains the
internal limiting membrane, Am J
Ophthalmol 2001; 131: 387-8.
Ho JD, Tsai RJ, Chen SN, Chen
HC. Cytotoxicity of indocyanine
green on retinal pigment
epithelium: implication for
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1. Aaberg TM. Macular holes: review. Surv Ophthalmol 1970:15:
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1988; 106: 629-39.
5. Kelly NE, Wendel RT. Vitreous
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Ophthalmol 1991; 109: 654-9.
6. Wendel RT, Patel AC, Kelly NE,
S a l z a n o T C , We l l s J W.
Ophthalmol 1993; 100: 1671-6.
7. Tanner V, Chauhan DS, Jackson
TL, Williamson TH. Optical
coherence tomography of the
vitreoretinal interface in macular
hole formation. Br J Ophtalmol
2001; 85; 1092-7.
8. Uemoto R, Yamamoto S, Aoki T,
Tsukahara I, Yamamoto T,
coherence tomography after
idiopathic macular hole surgery
with or without internal limiting
membrane peeling. Br J Ophthalmol 2002; 86: 1240-1242.
9. Ebato K, Kishi S. Sponateous
closure of macular hole after
posterior vitreous detachment.
Ophthalmic Surg lasers 2000; 31:
245-7.
10. Par DW, Sipperley JO, Sneed SR.
15.
16.
17.
36
21.
22.
23.
macular hole surgery. Arch
Ophthalmol 2003; 121:1423-9
Isomae T, Sato Y, Shimada H.
Shortening the duration of prone
positioning after macular hole
surgery- comparison between 1week and 1- day positioning. Jpn J
Ophthalmol 2002; 46:84-8.
van de Moere A, Stalmans P.
Anatomical and visual outcome
of macular hole surgery with
infracyanine green assisted
peeling of the internal limiting
membrane, endodrainage, and
silicone oil tamponade. Am J
Ophthalmol 2003; 136:879-87.
Ezra E, Gregor Z. Surgery for
idiopathic full-thickness macular
hole: two-year results of a
randomized clinical trial comparing natural history, vitrectomy,
and virtectomy plus autologous
serum: Moorfields macular Hole
Study Group Report No. 1 Arch
Ophthalmol 2004; 122:224-36.
Fekrat S, Wendel RT, de la Cruz
Z, Green WR. Clinico pathologic
correlation of an epiretinal
membrance associated with a
recurrent macular hole. Retina
1995;15:53-7.
Brooks HL Jr. Macular hole
surgery with and without internal
limiting membrane peeling.
Ophthalmol 2000;107:1939-48.
Stec L, Ross R, Williams G.
Vitrectomy for chronic macular
holes. Retina 2004;24:341-7.
Esculapio - Volume 07, Issue 04, October-December 2011
Original Article
Problems Faced by Lady Health Workers (LHWs) in Punjab Province
Saima Zubair, Tajammal Mustafa, Rubina Sarmad, Rabia Arshad Usmani, Humaira Zareen and Shamim Akhtar
Objective: To assess the problems faced by Lady Health Workers in Punjab province.
Material & Methods: This cross-sectional study was conducted in 9 union councils of Punjab
cu
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province. All 111 Lady Health Workers working in these nine union councils were included in the
study and were interviewed on a structured questionnaire.
Results: Ninety two percent of the LHWs faced problems while providing services. Ninety five
percent had salary related problems, seventy four percent had problems with supplies, thirty two
percent faced problems in community services, 44.1% had difficulties with health facility liaison,
56.7% faced problems due to workload, 44.1% had problems in traveling, 8.8% in supervision,
20.6% in monitoring, 9.8% in reporting, 29.4% in feedback, 36.3% in security; 14.7% faced
problems due to harassment, 18.6% due to training deficiency and 32.4% faced other problems.
Conclusion: Efforts must be focused to strengthen the program and increase the LHWs
capacity as efficient health care workers by involvement of LHWs' own views and addressing the
problems faced by them.
Keywords: Lady health workers, community workers, gender and female workers.
Introduction
community.
The importance of LHW cannot be under estimated
and all steps should be taken to strengthen their role.
This cannot be done without knowing and solving the
problems that are encountered by them. So evaluation
of problems faced by them is of grave importance
and their issues need to be highlighted and resolved.
Very little literature exists which has identified social
and cultural, along with organizational barriers to
efficient working of LHWs. Furthermore, no study
has so far looked at LHWs perspective of the
strengths and weaknesses of the program and how
their role in PHC may be strengthened within the
program.
Ri
gh
ts
@
Es
Health is a fundamental right of people and most of
the governments including Pakistan have taken
responsibility of provision of health care services to
all the people of their countries.
For achieving universal health coverage by addressing
PHC at community level, the Government of
Pakistan launched the National Program for Family
Planning and Primary Health Care (NPFP&PHC) in
April 1994. The program recruits local, literate girls as
LHWs and after 3 months of classroom sessions and
12 months of field training they are deputed in the
community. They work from their own house which
is declared as a Health House. Each LHW caters for
200 households or 1000 population. About 25 LHWs
are supervised by one supervisor.
LHWs are posted in their own communities and are
involved in organizing community by developing
women groups and health committees. They act as
liaison between formal health system and community
and are required to register all eligible couples
(married women age 15-49 years). LHWs disseminate
health education messages on hygiene and sanitation,
provide family planning services, undertake
nutritional interventions, coordinate with EPI for
immunization of mothers against tetanus and
children, carry out prevention and treatment of minor
ailments and coordinate with TBAs (traditional birth
attendants) and local health facilities.
Uptil now NPFP&PHC has more than 95,000 LHWs
working in almost every part of Pakistan and
providing primary health care facilities to the
py
Material & Methods
Co
It was a cross sectional descriptive study conducted in
9 union councils of Punjab province from 17th June
2008 to 17th July 2008. The study was conducted in
following union councils of the province (convenient
sampling):
1. UC Dhamthal No. 28, Tehsil and District
Narowal with 15 LHWs.
2. UCl C-1 of Walton Cantonment Board, Lahore
with 9 LHWs.
3. UC C-6 of Walton Cantonment Board Lahore
with 7 LHWs.
4. UC No. 110 Kharak District Lahore with 9
LHWs.
5. UC No. 32 Chak No.5 Kalan, District Nankana
Sahib with 7 LHWs.
6. UC No. 93 District Lahore with 7 LHWs.
37
Esculapio - Volume 07, Issue 04, October-December 2011
7. UC No. 179 District Faisalabad with7 LHWs.
8. UC No. 28 Sinawa District Muzzafargarh with 27
LHWs.
9. Islamabad Capital Territory UC No. 7 Kirpa with
23 LHWs.
supply was irregular and 19 (31.6%) complained of
deficiency of important medicines, 28 (36.8%) had
stationary related complaints. 27 (96.4%) said
stationary supply was deficient and 5 (17.8%) said that
stationary was of poor quality. 19 (25%) LHWs faced
problems due to weight machine. 2 (10.5%) said
mothers were hesitant to use weight machine for kids,
15 (78.9%) felt it was not suitable for infant use, 3
(15,7%) said there are problems in repair of the
weight machine and 3 (15.7%) felt need of adult
weight machine as well. 5 (6.5%) said provision of
BP apparatus was also necessary.
Table-5 depicts the problems in community services.
17 (51.5%) said there was resistance by males, 14
(42.4%) said there was resistance by females, 7
(21.2%) faced resistance to family planning and nonavailability of mothers, 6 (18.2%) said community
behaved rudely and 1 (3%) said there was resistance
during Oral Polio Vaccine campaign due to fear of
family planning.
Table-6 shows the problems in liaison with health
facilities. 22 (48.9%) had problems with Basic Health
Units, 21(46.7%) with Rural Health Centres, 7
(15.5%) with government hospitals and 2 (4.4%) with
private hospitals. 33 (73.3%) said there was no
cooperation from health facilities, 8 (17.7%) said
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pk
All lady health workers working in the study area were
included. The total number the LHWs in study was
111.The data was collected on standardized
questionnaires which included open ended questions
and all LHWs were directly interviewed. Part A was
based on socio-demographic information and part B
was related to the problems.
The data was entered into the computer, by using Epi
Data and Epi Info version 3.5.1 was used to analyze
the data. The permission from EDOs(H) and District
coordinators of NPFP&PHC was sought formally.
Confidentiality was ensured by not disclosing the
identity of participants of the study to any body.
cu
Results
Table-1: Socio-demographic characteristics of lady
health workers (n=111).
ts
@
Es
Table-1 shows the socio-demographic characteristics
of the LHWs. There were 35 (31.53%) LHWs
between 20-30 years of age, 43 (38.73%) LHWs
between 31-40 years of age and 33 (29.72%) were
between 41-50 years of age. Educational status of the
LHWs ranged from middle to graduate; 22(19.81%)
LHWs were middle, 45(40.54%) LHWs were matric,
32 (28.82%) LHWs were F.A. and 2 (1.8%) LHWs
were graduates. 80 (72.07%) were married, 21(18.9%)
were unmarried & 10(9.02%) were divorced/widow.
All had income less than Rs. 3000 per month.
Table-2 shows the problems faced by LHWs while
providing services. 102 (91.89%) LHWs said that they
faced problems. 95 (93.1%) had salary related
problems, 76 (74.5%) had problems with supplies, 33
(32.4%) in community services, 45 (44.1%) with
health facility liaison, 58 (56.7) faced problems due to
workload, 45(44.1%) had problems in traveling, 9
(8.8%) in supervision, 21 (20.6%) in monitoring, 10
(9.8%) in reporting, 30 (29.4%) in feedback,
37(36.3%) in security, 15 (14.7%) faced problems due
to harassment, 19 (18.6%) due to training deficiency
and 33 (32.4%) faced other problems.
Table-3 shows the salary related problems faced by
LHWs. 67 (70.5%) said the salary was low. 55 (57.8%)
complained of delayed payments. 3 (3.2%) reported
deductions in their salary.
Table-4 shows the frequencies of LHWs facing
hardships due to problems of supplies. 60 (78.9%)
had problems in medicine supply. 27(45%) said they
received inadequate medicines, 47 (78.3%) said
gh
Number
Percentage
py
Ri
Age in Years
20 - 30
35
31.53
31 - 40
43
38.73
41 - 50
33
29.72
Married
80
72.07
Unmarried
21
18.91
Divorced /Widow
10
9.02
Middle
22
19.81
Matric
45
40.54
FA
32
28.82
2
1.8
111
100
Co
Marital Status
Educational Status
Graduate
Income
Less than 3000 Rs.
38
Esculapio - Volume 07, Issue 04, October-December 2011
Table-2: Problems faced by LHWs while providing
services.
Percentage
Number
(33.3%) said LHS was overworked. 15 (71.4%)
complained of irregular monitoring, 5 (23.8%) said
monitoring was excessive and 1 (4.7%) said they were
over monitored during campaigns. 7 (70%) said there
was duplication in reporting and 9 (90%) said
reporting was difficult. 29 (96.7%) said there was no
feedback by department and 5 (16.7%) said there was
no appreciation. 10 (52.6%) felt training deficiency in
antenatal care, 6 (31.5%) in labor room and 7 (36.8%)
in referral. Table-9 depicts the problems in personal
protection of LHWs. Traveling problems were due to
non-availability of transport in 18 (40%) cases, 17
(37.7%) at night, 11 (24.4%) as no TA/DA was given
and 3 (6.7%) due to weather. 34 (91.8%) complained
of occasional security problems, 12 (32.4%) had
security problems when they went to different areas.
Of those who faced harassment 15 (100%) faced
occasional harassment, 11 (73.3%) during campaigns,
11(73.3%) faced eve teasing, 4 (26.7%) faced physical
harassment, 10 (66.7%) faced it from community
members and 4 (26.6%) from colleagues. Table-10
shows various problems faced by LHWs. 8(24.4%)
said they were being charged for supplies. 6(18.2%)
had problems in provision of services related to
sanitation. 4(12.2%) said that trainings in far-off areas
makes it difficult for them. 17(51.4%) mentioned
vague problems.
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pk
patients were mistreated, 6 (13.3%) said LHWs were
maltreated, 3 (6.7%) complained that referral slip was
not signed and 20 (44.4%) said that doctors were not
available at health facilities.
Table-7 shows workload related problems faced by
LHWs. 40 (68.9%) said they are overworked. 14
(24.1%) said workload is increased during campaigns,
8 (13.7%) felt there was excessive paper work, 6
(10.3%) were stressed due to political gatherings and
2 (3.4%) said workload increased after trainings.
Table-8 describes the department related matters
causing problems for LHWs. 6 (66.7%) had
supervisory problems due to vacant LHS posts and 3
102
91.89
No
09
8.11
Salary
95
93.1
Supplies
76
74.5
Community Services
33
32.4
Health faciltiy liaison
45
Workload
58
56.7
Travelling
45
cu
Yes
@
lap
Do you face problems while providing services? (n=111)
Es
Various problems (n=102)
44.1
The study was conducted to identify problems faced
ts
gh
Discussion
Table-4: Supplies related problems of LHWs (n=76).
44.1
Yes
Percentage
A. Medicine (n=60)
60
78.9
1. Inadequate
27
45
29.4
2. Irregular Supply
47
78.3
37
36.3
3. Deficient important medicines
19
31.6
15
14.7
B. Stationary (n=28)
28
36.8
Training deficiency
19
18.6
1. Deficient
27
96.4
Any other
33
32.4
2. Poor quality
5
17.8
19
25
2
10.5
15
78.9
Supervision
Reporting
21
20.6
10
9.8
30
py
Feedback
Co
Security
Harassment
8.8
Ri
Monitoring
9
C. Weight machine (n=19)
* Multiple responses allowed
Table-3: Salary related problems faced by LHWs (n=95).
1. Mothers hesitant
Yes
Percentage
Low salary
67
70.5
3. Adult wight machine required
3
15.7
Late payments
55
57.8
4. Repair problem
3
15.7
Deductions
3
3.2
D. BP Apparatus
5
6.5
2. Unsuitable for infants
*Multiple responses allowed
*Multiple responses allowed
39
Esculapio - Volume 07, Issue 04, October-December 2011
Table-5: Problems faced by LHWs in provision of
community services (n=33).
Percentage
Resistance by Males
17
51.5
Resistance by Females
14
42.4
Resistance during campaigns
1
3
Resistance to family planning
7
21.2
Resistance to OPV (fear of family planning)
1
3
Mothers not available
7
21.2
Do not show newborn
1
3
Rude behavior
6
18.2
Table-7: Workload problems faced by LHWs (n=58).
Number
cilities (n=45).
Rural health centre
21
46.7
Government hospital
7
15.5
Private hospital
2
4.4
No cooperation
33
Mistreatment of patient
8
Mistreatment of lady health worker
6
*Multiple responses allowed
Paper work
8
13.7
Increased after campaigns
2
3.4
Political gatherings
6
10.3
Table-8: Supervisory, monitoring, and training related
problems (n=102).
Supervision (n=9)
Number
Percentage
9
8.8
17.7
LHS post vacant
6
66.7
13.3
LHS overworked
3
33.3
ts
gh
Doctor not available
24.1
*Multiple responses allowed
73.3
3
6.7
Monitoring (n=21)
21
20.6
20
44.4
Excessive
5
23.8
Over during campaigns
1
4.7
15
71.4
Reporting (n=10)
10
9.8
Duplication
7
70
Difficult
9
90
30
29.4
29
96.7
5
16.7
19
18.6
10
52.6
Labor room
6
31.5
Referral
7
36.8
Ri
Refferal slip is not signed
14
Es
48.9
@
22
Increased during campaigns
cu
Percentage
Basic health unit
68.9
lap
Table-6: Problems related to liaison with health fa-
Percentage
40
Over worked
*Multiple responses allowed
Number
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pk
Number
broadly fits into the definition of community health
worker, and is a crucial component of the health care
delivery system of the country. The Lady Health
Workers Program (LHWP) is a federally funded
development program working at the grass root level
since 1994. About 96,000 workers and their
supervisors have been trained and deployed in all the
135 districts of Pakistan. They currently cover about
65% of the target population (rural and urban slums),
and full coverage is planned in the next few years.
Irregular
Co
py
by LHWs in order to facilitate the provision of their
services. About a quarter of the LHWs were found
to have significant occupational stress. Factors
associated with stress included having low socioeconomic status and having to travel long distances
for work. Inconsistent medical supplies, inadequate
stipends, lack of career structure and not being
equipped to communicate effectively with families
were the main factors for job dissatisfaction among
these workers. Improvement in remuneration, better
administration of supplies and a structured career
path should be ensured for better performance of
community health workers. In addition,
communication skills learning should be an essential
part of their training program.The "Lady Health
Worker" (LHW) of the National Program for Family
Planning and Primary Health Care in Pakistan
Feedback (n=30)
Nil by department
No appreciation
Training deficiency (n=19)
Antenatal care
*Multiple responses allowed
40
Esculapio - Volume 07, Issue 04, October-December 2011
45
44.1
Weather
03
6.7
Transport
18
40
Not at night
17
37.7
No TA/DA
11
24.4
Security (n=37)
37
36.3
Occasional
34
91.8
Different Area
12
32.4
Harassment (n=15)
15
14.7
Occasional
15
100
During campaign
11
73.3
Eve Teasing
11
73.3
Physical
05
26.7
Community
10
66.7
Colleagues
04
26.6
@
*Multiple responses allowed
lap
Traveling (n=45)
cu
Percentage
Es
Yes
Table-10: Other problems faced by LHWs (n=33).
Percentage
ts
Number
Community sanitation
06
Training in far off area
04
Miscellaneous
gh
08
Ri
24.4
Changes for supplies
17
18.2
12.2
51.4
py
*Multiple responses allowed
say can result in occupational stress. This condition
defined as "any physical or psychological event
perceived as potentially constituting physical harm or
emotional distress", if present in health workers
depicts the problems in community services and can
have an adverse impact on their efficiency.
The program succeeded in creating a large sized
organization comprising of female community health
workers and establishing a functional program
management and supply system. It found evidence
that the program improved the uptake of important
health services in areas covered by its LHWs. At the
same time it recommended that the quality of work
needed improvement. Efforts must be focused to
strengthen the program and increase the LHWs
capacity as efficient health care workers.
But there was no information on the LHWs' own
views about their job description and levels of
occupational stress. These factors would be important
in the improvement of quality of service delivery and
under performance/utilization of existing LHWs.
The domain in general is poorly researched and
systematic reviews have pointed out knowledge gaps
in areas like job satisfaction/dissatisfaction and job
retention/attrition describes the department related
matters causing problems for LHWs.
The most common problem reported was dealing
with administrative inefficiency such as irregular
supply of medicines and vaccines (70%) and not
getting their salary on time. Inadequate salary was the
next biggest problem reported by over 60% of the
respondents. Other problems included difficulty
motivating mothers and families to get their children
immunized and take preventive measures, difficulty in
communicating on family planning issues, non
cooperative attitude of community and inadequate
information, education, communication (IEC)
material and other job aids.
The potential role of CHWs in improving
community health has been acknowledged especially
47
in resource poor countries. Haines et al have
described that owing to the inverse relationship of
density of health workers (doctors, nurses, midwives)
with maternal, infant and under 5 mortality coupled
with high cost of training of doctors and nurses and
the low use of services based in health facilities in
many areas, there is a possibility to make substantial
health gains from the use of community health
workers. The Task Force for Scaling up Education
and Training for Health Workers48 recommended
io.
pk
Table-9: Difficulties faced by LHWs related to travelling and personal protection (n=102).
Co
The job description of the LHW has evolved over
time. Initially it included health education and basic
preventive services for family planning, maternal and
child health, improving nutrition, basic hygiene and
sanitation and child immunization. Today it also
includes mass immunization for polio eradication;
newborn care, maternal immunization with tetanus
toxoid (TT), referral of eligible cases to health
facilities, regular record-keeping for updating the
management information system (MIS) of the
program, community management of tuberculosis
and health education on HIV-AIDS and Hepatitis.
Lady Health Workers are seldom consulted when
their job description changes. This ever-enlarging
scope of work of the LHW in which they have little
41
Esculapio - Volume 07, Issue 04, October-December 2011
improving education of these workers through
quality assurance programs and urged international
action to scale up the production of quality health
workers.
Other studies have also reported areas for
improvement in the structure and performance of
CHW programs including the LHWP of Pakistan.
The low salary and lack of career path was highlighted
17
by Afsar et al as a reason for job dissatisfaction
among the LHWs. Mumtaz et al40 reported abusive
hierarchical management structure, disrespect from
male colleagues, lack of sensitivity to women's
gender-based cultural constraints, conflict between
domestic and work responsibility and poor
infrastructural support as the important problems
faced by female primary health care workers from
their study conducted in 1998 when the program was
only four years old. Our study suggests that the
disrespect from male colleagues and conflict between
domestic and work related responsibility has
improved while the other factors remain the same.
Douthwaite & Ward49 found that the LHWP
succeeded in increasing the use of modern
contraceptives by rural women. According to them
women served by LHWs were significantly more
likely to use a modern reversible method than women
in communities not served by LHWs after controlling
for various individual and household characteristics.
They advocated for continuation of providing
doorstep services through community-based workers
to achieve universal access to safe family planning
methods. Our study suggests that communication on
family planning is still perceived as a difficult area by
these workers and, while the program should be
continued, some interpersonal communication (IPC)
capacity building measures are needed to further
improve performance and outcome.
Multifaceted interventions (e.g. training plus
supervision) which address multiple determinants of
performance have been recommended50 to improve
CHW performance. We add that improvement in
remuneration; clear career path and improved
administration are also required. In addition,
empowering communication techniques should be
built into the training and on-going supervision
processes to improve the effectiveness of the
community health workers.
Independent evaluations of the program conducted
to date have shown mixed results, with some regions
in the country performing better than others. The
evaluation conducted by the Oxford Policy
Management, UK, reports that the performance of
lap
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pk
about 17% of LHWs was poor and 35% was below
average. Moreover, the government’s decision to
introduce a more comprehensive reproductive health
package5 would increase LHWs responsibilities and
could further decrease efficacy. Therefore, efforts
must be focused to strengthen the program and
increase the LHWs capacity as efficient health care
workers.
In low income countries, the task of providing
primary health care is often the responsibility of
community health workers. In Pakistan, community
workers called Lady Health Workers (LHW) deliver
basic health care at the doorstep in the rural areas and
urban slums. Evaluations show that it is a successful
program but point out inconsistencies in the quality
of service provided. In order to achieve this, it would
be important to obtain the workers' viewpoint on
their job-description, the problems they face and the
levels of problems they encounter.
cu
Conclusion
Co
py
Ri
gh
ts
@
Es
After 15 years of the National Program for Family
Planning and PHC has acquired maturity, and has
expanded from a limited pilot project to an enormous
program with nation wide coverage. The workers
form an invaluable body of skilled human resource,
the services of whom are often utilized for many
other programs. LHWs have mostly succeeded in
establishing trust and community acceptability and
are providing essential PHC services across the
country. This is all the more significant in a culture
where government programs are considered suspect
by most. The following recommendations are being
made with the aim to strengthen the role of LHWs in
PHC in Pakistan.
• LHWs should be made permanent government
employees with all relevant benefits after an initial
probation period.
• Salaries should be increased and salary disbursement mechanism be made efficient
• Eligible LHWs be given incentives (skills, career
development, financial) and positive feedback for
motivation
• Any incentives or remuneration policies must
always be monitored and adapted over time to
ensure that they produce the desired outcome
• Community be educated about assigned role and
responsibilities of LHWs
• Program staff must not be involved in other
programs like polio eradication campaigns
42
Esculapio - Volume 07, Issue 04, October-December 2011
•
•
•
•
•
Patient referral system by the LHWs must be
strengthened and referrals by LHWs be given
priority at FLCFs
A mix of payment systems and incentives should
be used where possible. If institutional capacity
is limited, caution should be exercised in
adopting approaches with complex administrative requirements
The number of LHWs should be increased to
cover the whole population.
•
•
Workload of LHWs should be equalized.
Supply of medicines should be regularized and
increased.
Refresher trainings should be given regularly.
Regular feedback should be taken from LHW for
improvement of program
Department of Mother & Child Health
Institute of Public Health, Lahore
theesculapio@hotmail.com
www.sims.edu.pk/esculapio.html
12.
py
Co
13.
14.
sector health worker motivation:
a conceptual framework. Soc Sci
Med. 2002; 54 (8): 1255-66.
15. Hassan M. Medical ethics: past
and present. Pak Heart J1995; 28:
63-72.
lap
gh
ts
11.
@
Es
cu
10.
The Aga Khan University, Karachi
in collaboration with Ministry for
P o p u l a t i o n a n d We l f a r e
Government of Pakistan and
UNDP 1999.
Evaluation report: Briefing note
for Sindh survey report. National
Program for family planning and
Primary Health Care, Ministry of
Health (MoH), Government of
Pakistan, Oxford policy
management March 2002.
[Accessed on Aug 25, 2008].
Ava ila b le a t URL:
http://phc.gov.pk/sindh.php.
Afsar HA, Qureshi AF, Younus M,
Gul A, Mahmood A. Factors
effecting unsuccessful referrals by
the Lady Health Workers in
Karachi Pakistan. J Pak Med Assoc.
2003; 53: 521-8.
Hasan A. A model for
government-community partner
ship in building sewage systems for
urban areas: the experiences of the
Orangi pilot project Research and
Training Institute (OPP-RTI),
Karachi. Water Sci Technol. 2002;
45(8): 199-216.
A f s a r H A , Yo u n u s M .
Recommendations to strengthen
the role of lady health workers in
the national program for family
planning and primary health care in
Pakistan: the health workers
perspective. Department of
Community Health Sciences, The
Aga Khan University, Karachi and
N a t i o n a l Fo o d S a f e t y a n d
Toxicology Center, Michigan State
University, USA.
Franco LM, Bennett S, Kanfer R.
Health sector reform and public
Ri
1. Declaration of Alma Ata,
International conference on
Primary Health Care, Alma-Ata,
USSR, 6-12 September 1978.
WHO/OMS, 1999.[Accessed on
August 8, 2008] Available at
URL: http://www.who.int/
hpr/archive/docs/almaata.html.
2 . Wo r l d B a n k . T h e wo r l d
development report: Investing in
Health. Washington DC: Oxford
University Press 1993.
3. United Nations Children's Fund
(UNICEF), State of the worlds
children 1998: Oxford University
Press. 1998: 120-21.
4. United Nations Children's Fund
(UNICEF), Statistics: Pakistan.
[Accessed on August 18, 2008]
Available at URL:
http://www.unicef.org/satis/
Country_1page132.html.
5. Revised PC-1, Prime Ministers
Program for Family Planning and
Primary Health Care, Ministry of
Health (MoH), Government of
Pakistan 1993.
6. Cumbey DA, Alexander JW. The
relationship of job satisfaction
with organizational variables in
public health nursing. J Nurs
Adm. 1998; 28(5): 39-46.
7. Eastern Mediterranean Region
WHO. Pakistan Country Profile
2005-2006. Wo rld Health
Organization.
8. Khan MH, Saba N, Anwar S,
Baseer N, Syed S. Assessment of
knowledge, attitude and skills of
lady health workers. Journal of
Medical Sciences. 2006; 4(2): 58.
9. The Client Record Card Project
(CRC), Department of
Community Health Sciences,
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References
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17. Afsar HA, Qureshi AF, Younus
M, Gul A, Mahmood A. Factors
effecting unsuccessful referrals
by the Lady Health Workers in
Karachi Pakistan. J Pak Med
Assoc. 2003; 53: 521-8.
18. Hull FM, Wester man RF.
Referral to medical out-patient
departments at teaching hospitals
in Birmingham and Amsterdam.
BMJ.1986; 293: 311-4.
19. Ndiwane A. The effects of
community, coworker and
organizational support to job
satisfaction of nurses in
Cameroon. ABNF J. 2000; 11(6):
145-9.
20. Franco LM, Bennett S, Kanfer R.
Health sector reform and public
sector health worker motivation:
a conceptual framework. Soc Sci
Med. 2002; 54 (8): 1255-66.
21. World Health Report 2006.
22. Chowdhury AMR, Cash RA. A
simple solution: teaching millions
to treat diarrhoea at home.
Dhaka, University Press, 1996.
23. The world health report 2004
Changing history. Geneva, World
Health Organization, 2004.
24. Jokhio HR, Winter HR, Cheng
KK. An intervention involving
traditional birth attendants &
perinatal & maternal mortality in
Pakistan. NEJM 2005; 352: 20919.
Esculapio - Volume 07, Issue 04, October-December 2011
Case Report
AIDS And Its Complications.
A Case Report And Review Of The Subject
Farrukh Iqbal and Abdul Rashid Sheikh
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Abstract: Infection with HIV causes a spectrum of clinical problems beginning at the time of
seroconversion (primary HIV) and terminating with full blown Acquired Immune deficiency
Syndrome (AIDS) and death. This article describes the case of a 45-year-old gentleman who
presented with 2 months history of fever and weight loss. He was diagnosed as a case of HIV on
Elisa testing. He had extremely low CD 4 count and was suffering from opportunistic infections like
Pneumocystis Carinii Pneumonia (PCP). The literature is reviewed on AIDS with a special focus
on recent advances and highly active antiretroviral therapy.
Keywords: HIV, AIDS, PCP
Investigations
Results
Hb
8.9 g/dl
cu
A 38 year-old gentleman of foreign nationality was
admitted in hospital through Accident and
emergency department with a history of drowsiness
for last 3 days. Detailed history was taken from
attendants. Patient had complaints of feeling unwell,
malaise, non productive cough for the last 10 days,
which was preceded by history of low-grade fever,
loss of appetite, and generalised weakness for the last
2 months. He was a chain smoker and had significant
history of alcohol intake. There was no history of
drug addiction. He was a businessman by profession
and used to travel abroad to different countries and
had frequent sexual relations with prostitutes. He was
divorced with one daughter who was not living with
him either His father was a diabetic and hypertensive.
Other members of his family were healthy.
On examination, the patient was markedly emaciated,
and was in altered state of consciousness with a GCS
of 8/15. He had marked pallor and clubbing. He had
bilateral palmer erythema probably due to alcohol
abuse and liver involvement secondary to it. Left
anterior and posterior cervical chains of lymph nodes
were palpable. He had also developed a bed sore at
sacral area. He also looked dehydrated and was so
weak that he had to be moved with assistance. His
pulse rate was 110/min, regular and low volume and
blood pressure was 100/70 without postural drop.
He was afebrile on admission.
He had signs of meningeal irritation, increased tone
in all limbs, normal reflexes and non-specific plantars.
Power was 2/5 in all limbs. Sensory system could not
be assessed due to patient's altered state of
consciousness. There were bilateral coarse
creptitations in the chest. Cardiovascular and
abdominal examinations were unremarkable.
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Table-1: Initial basic investigations were as follows.
Introduction
73x10 /lL
PT (Control 13.0)
14.0 Sec
APTT (Control 30.0)
45.0 Sec
TLC
2.2x109 /lL
ESR
90 mm in 1st hr
Polymorphs
85 %
Lymphocytes
95 %
Monocytes
03 %
Eosinophils
02 %
Bands
05 %
Bands
25,000
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Platelets
9
Co
Peripheral blood picture showed anisopoikilocytosis,
macrocytosis, acanthocytes, fragmented cells,
elliptocytes and spherocytes. Malarial Parasites were
not found on slides. Urine, stool and blood culture
and sensitivity did not show any growth of organisms.
Renal function tests and LFTs were normal initially.
Among electrolytes, sodium was 128 mmol/ L,
calcium 6.7mg/dl with albumin of 2.0g/dl. Serum
ammonia was 253.
In view of his drowsiness and neck rigidity CSF
examination was carried out which showed that
glucose was low and proteins were high. Blood sugar
level was 130 mg/dl. TLC was 03/cmm with 100 %
lymphocytes. ZN Stain for AFB, Gram Stain,
culture/sensitivity and cytology for malignant cells
44
Esculapio - Volume 07, Issue 04, October-December 2011
Firstly, it was thought that this patient might have
pulmonary tuberculosis perhaps with tuberculous
meningitis, explained by raised ESR, low sodium,
high protein and low glucose in CSF. Therefore he
was started on anti tuberculous therapy, keeping an
eye on LFTs and other parameters. He was also
started on high dose co-trimoxazole, thinking strong
possibility of Pneumocystis carinii pneumonia. He
was also given broad spectrum antibiotics
parenterally along with g ancyclovir for
cytomegalovirus infection. Other treatment was
mainly supportive in the form of blood transfusion,
intravenous fluids, multi vitamins, intravenous
albumin and parenteral nutrition. Bed sore was
treated with daily washing it with normal saline,
dressing and postural changes. Initially there was mild
improvement but then patient's consciousness level
fluctuated during the course of treatment with spikes
of fever and his total leucocytes count continued to
drop.
His repeat chest X-rays did not show any resolution
of Pneumocystis carinii pneumonia inspite of
treatment. Patient's general condition deteriorated.
He went into deep coma and expired about 3 weeks
after admission. The final diagnosis was a full blown
Immunod- eficiency syndrome with all its
recognisable complications except Kaposi Sarcoma
i.e. Pneumocystis carinii pneumonia and Cytomegalovirus infection. Although he was given whatever
treatment was available but he could not be given
highly active antiretroviral therapy due to lack of
facilities and a specialised unit. He could not be
transferred to his own country, which had facilities,
due to his very critical condition and extremely low
CD4 count.
Here is a review of the literature about current
concepts related to AIDS.
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were all negative.
Hepatitis B and C serology, dengue IgG and IgM were
all negative; however HIV 1&2 antibody test by Elisa
was repeatedly strongly positive from two different
laboratories. Cytomegalovirus IgG and IgM were also
positive.
Chest X- Ray showed infective patchy and nodular
infiltrates in both lungs together with right
paratracheal lymphadenopathy (See Figure-A).
Ultrasound abdomen showed peri-portal and coeliac
lymphadenopathy. MRI Brain with contrast showed
mild to moderate dilatation of ventricular system and
a tiny remote infarct in posterior limb of internal
capsule. (See Figure- B)
py
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Figure-A: X-Ray chest.
Literature Review
Co
Human immunodeficiency virus (HIV) is a retrovirus
that can lead to Acquired Immune Deficiency
Syndrome (AIDS), a condition in which the immune
system begins to fail, rapidly leading to life1
threatening complications. Epidemiology of AIDS
is sown in the following table (Table 1) 2 in a simplified
way. In Pakistan HIV prevalence rates among
intravenous drug abusers ranged between 10 to 50
percent in and around Quetta, Faisalabad,
Hyderabad, Karachi, and Sargodha. Surveillance data
for 2006 point to a local concentrated epidemic
among male sex workers and transgenders in Larkana
and Karachi in the Sindh province while prevalence
3
elsewhere is still below 5 percent.
Figure-B: CT scan brain.
45
Esculapio - Volume 07, Issue 04, October-December 2011
Table-1: Epidemiology of AIDS worldwide.
Region
Incidence (millions)
Prevalence (millions)
Deaths (millions)
Globally
33.2
2.5
2.1
Sub-Saharan Africa
25.4
3.1
2.3
East Asia
1.1
0.29
0.051
South and South-East Asia
7.1
0.89
0.49
Table-2: (HIV/AIDS in Pakistan )
People living with HIV/AIDS
People dying with AIDS
ARV Need
People on ARV Treatment
85,000
3,00
12,000
<200
0.1
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Adult HIV Prevalence (%)
Table-3: Transmission of AIDS.
High Risk Groups
Sexual
Unprotected sex, homosexuals, multiple sex partners
Blood or blood product route
IV drug abusers, haemophiliacs, recipients of blood products, reuse of
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Route
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Needles in third world countries, health care workers, people receiving
Tattoos and piercing of different parts of their body e.g. ear, tongue, skin etc.
Mother-to-child transmission ( MTCT)
Es
During pregnancy and intrapartum route at childbirth. Breast feeding
Table-4: The pathophysiology of AIDS.
@
Saliva, tears and urine of infected individuals Potential risk of transmission is negligible
Pathology
Cd4 + Lymphocytes
Place for most of HIV replication. Progressive depletion due to sequestration in inflammed
ts
Immune defences
gh
Lymphoid tissues, diminished production due to cellular hypo productivity in bone marrow
In early HIV infection, CD8+ T-cell numbers tend to increase, reflecting expansion of
CDB + T lymphocytes
B lymphocytes and antibody production
Hyper activation and hypo responsiveness
Impaired function
py
Monocytes, macrophages
Ri
Memory Cd8+ T cells, particularly HIV-reactive cells. In advanced stages CD 8 decreases.
Co
Table-5: Indications for starting therapy for AIDS.
Symptomatic or Cd4 < 200
Definitely start treatment
Cd4 200-350
Evidence supporting treatment.
CDR > 350
Data equivocal. Some cohort studies show treatment benefit, but magnitude of difference is small.
Viral load (VL) > 100,000
Independent indicator of need for therapy
Table-6: Indications for prophylaxis against opportunistic infections encountered in AIDS.
CD Count < 200
Pneumocystis jiroveci pneumonia
CD Count < 100
Mycobacterium avium complex and toxoplasmosis
PPD reaction > 5mm Induration
Mycobacterium tuberculosis
CD Count < 50 and CMV antibodies present
Independent indicator of need for therapy
46
Esculapio - Volume 07, Issue 04, October-December 2011
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Table7: Treatment of aids-HAART (highly active ant- components especially lymphocytes. It is highlighted
in the Table 4.
iretroviral therapy) .
The clinical features of AIDS comprise a long list
Group
Mechanism
Sub Group
Dose
Remarks
Side Effects
Nucleoside
Tenofovir–
Prevent
HIV Lamivudine
300
Peripheral
however the more often encountered signs and
reverse
Emtricitabine
DNA synthesis (3TC)
mg OD neuropathy,
transcriptase
combination
Rhabdomyolysis
symptoms include fever, night sweats, lymphad
inhibitors
has superior
Tenofovir
245
Renal dysfunction
(NRTI)
outcome in this
mg OD
group. Other
enopathy, chills, weakness, maculopapular rash and
Abacavir
300
Hypersensitivity
options are
mg BD reactions
Abacavir plus
Didanosine
400
Peripheral
weight
loss. Opportunistic infections e.g. recurrent
lamivudine, or
(ddI)
mg OD neuropathy,
zidovudine plus
Pancreatitis
oral
candidiasis,
pulmonar y tuberculosis,
lamivudine.
Emtricitabine
200
Reversible skin
Lactic acidosis
(FTC)
mg OD pigmentation
Pneumocystis
carinii
pneumonia and Cytomegaloand hepatic
Zidovudine
300
Anemia,
8, 9
steatosis is
(ZDV, AZT)
mg BD Neutropenia
virus
are
also
common.
common with
Stavudine
40mg
Lipoatrophy
all NRTI.
(d4T)
BD
Long-term
The diagnosis of AIDS is extremely important as it
exposure is
associated with
should
be diagnosed on time otherwise
mitochondrial
dysfunction.
complications
may be lethal. Lymphopoenia with
NonInhibitors
of Efavirenz
Efavirenz is
600
CNS Toxicity,
nucleoside
DNA synthesis
preferred as
mg OD Teratogenic
depression of the CD4 cell subset is a marker for HIV
reverse
first line anchor
Nevirapine
200
Stevens-Johnson
transcriptase
drug.
mg BD syndrome,
disease. Mild to moderate neutropoenia and a
inhibitors
Hepatotoxicity
(NNRTI)
nor mochromic, nor mocytic anaemia and
Protease
200
Unconjugated
Ritonavir plus
These
drugs Atazanavir
inhibitors
mg OD hyperbilirubinemia
Lopinavir are
Prevent
10
currently
the
cleavage
of Darunavir
600
Generally well
thrombocytopoenia
are common. Screening is done
preferred
HIV
proteins
mg BD tolerated
option for first
and
viral
by Enzyme-Linked Immunosorbent Assay (ELISA)
line
protease
maturation
Indinavir
800
Renal stones
11
inhibitors.
mg
and
confirmation by Western Blot or HIV PCR.
There
is
TDS
increased risk
Lopinavir
400
Gastrointestinal
Treatment of AIDS has been entirely revolutionized
of myocardial
mg BD symptoms,
Lipid abnormalities infarction which
seems to be
in the recent past and to make it simplified, Table 5
associated with
protease
shows
various groups of antiretroviral agents, their
inhibitors.
Entry
Prevent entry Enfuvirtide
90 mg Severe local site Used
in
mechanism
of action, dose and major side effects
inhibitors
of HIV into
S/C
reactions
patients
with
12-25
CD4 cells
BD
highly resistant
along with few remarks.
HIV.
HIV
Raltegravir,
Prevent
Having described the treatment of AIDS as an overall
integrase
integration of Elvitegravir
inhibitors
HIV DNA into
the
host
review, it is also important to know about the
genome
indications of anti-AIDS therapy as not all patients
suffering
from AIDS syndrome require all the
In Pakistan the incidence is shown in Table 2. 2
treatment modalities or therapeutic agents as such.
In Pakistan HIV prevalence rates among intravenous There are certain indications for the treatment of this
drug abusers ranged between 10 to 50 percent in and condition to follow. Table 6 shows this as follows. 26,27,
around Quetta, Faisalabad, Hyderabad, Karachi, and 28.
First line regimen should include two NRTI and a
Sargodha. Surveillance data for 2006 point to a local
third "anchor" drug that can be either a NNRTI or a
concentrated epidemic among male sex workers and
29.
transgenders in Larkana and Karachi in the Sindh protease inhibitor. Starting HAART may present
province while prevalence elsewhere is still below 5 with Immune reconstitution syndrome that results in
worsening of a pre-existing condition or new
3
percent.
opportunistic infection especially in those with CD 4
Though development of Highly Active Antiretroviral
30
Therapy ( HAART ) as effective therapy for HIV count <50. Interrupting therapy is usually associated
infection and AIDS has substantially reduced the with rapid loss 31of32 CD4 T cells and is not currently
death rate from this disease, the number of persons recommended.
4
living with AIDS has also increased substantially. In The antiretroviral therapy may lead to many adverse
some African countries , Cambodia ,South India and reactions and the case may become more
Thailand, better surveillance, behaviour change and complicated. Moreover, AIDS syndrome has its own
death among HIV affected people, has helped to slow complications including many atypical and
opportunistic life threatening infections and its
4
the epidemic. However in developing countries only
33
20 % of HIV infected individuals have access to management is shown in Table 7. As shown above
there are a number of complications due to AIDS,
5
antiretroviral drugs.
but quite a few of them can be prevented by giving
There are different modes of transmission for AIDS
prophylaxis against those infections depending upon
6, 7
and it is shown in Table 3.
the level of CD counts and various antiviral
The pathophysiology of AIDS is a bit complicated as
33
antibodies which is shown in Table-8. As shown
it involves immune system and its important
above there are a number of complications due to
47
Esculapio - Volume 07, Issue 04, October-December 2011
Table-8: Treatment of complications due to AIDS.
Complications
Treatment
Pneumocystis jiroveci pneumonia
Trimethoprimsulfamethoxazole. Adjunctive corticosteroids in case of hypoxemia.
Severe Cases: IV pentamidine
Pyrimethamine and sulfadiazine
Cytomegalovirus
IV ganciclovir
Tuberculosis
Anti tuberculous therapy
Oral candidiasis
Fluconazole for 10-14 days
Kaposi sarcoma (KS)
Cutaneous KS: Alitretinoin gel, Advanced KS: PLD (Pegylated liposomal
Doxorubicin) and radiotherapy
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Toxoplasmosis
Erythropoietin reduces need for blood transfusions
Mycobacterium avium complex
Clarithromycin, ethambutol and Rifabutin
Cryptococcal meningitis
Amphotericin B
AIDS wasting syndrome
Bisphosphonate and testosterone
Nutritional deficiency
No conclusive evidence that micronutrient and macronutrient supplementation
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Anemia
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reduces morbidity and mortality.
Table-9: Prevention of AIDS.
High Risk Groups
Barrier contraceptives
Reduce the probability of HIV transmission per sex act by as much as 95%.
Male circumcision
Medically performed can reduce the acquisition of HIV infection in men by at least 50%.
Nonoxynol-9
@
Route
ts
There is no evidence that protects against vaginal acquisition of HIV infection by women
gh
from men. There is evidence that it may do harm by increasing the frequency of genital lesions.
A combination of zidovudine and lamivudine given to mothers in the antenatal,
child transmission of HIV
intrapartum and postpartum periods and to babies for a week after delivery
Ri
To reduce mother-to
AIDS, but quite a few of them can be prevented by
giving prophylaxis against those infections depending
upon the level of CD counts and various antiviral
antibodies which is shown in Table 9. 33
Co
py
marginalized populations like the intravenous drug
users and transvestites in Karachi, which, according
to a study conducted by Family Health International
(FHI), have a high potential of being passed on into
the general population due to a closely weaved social
41
network.
The Pakistan National AIDS Control Programme
(NACP) is the one organization that coordinates
national AIDS strategies. In the present scenario,
HIV/AIDS prevention and control in Pakistan has
gained attention due to donor driven pressure and
allocations of large amounts of funding ($40 million
USD) through a comprehensive, five-year enhanced
HIV/AIDS program (2003 2008) executed by
NACP under the leadership of the Ministry of Health
(Government of Pakistan) with financial assistance
from the World Bank and other bilateral donors such
HIV In Pakistan 38
Pakistan is perceived as a 'high risk low prevalence
country' concerning the HIV/AIDS virus. According
to official government figures, there are 2,622 HIV
39
and 321 AIDS cases in the country. However,
according to UNAIDS estimates, HIV/AIDS cases
are under-reported in the country and perhaps
prevalent among 70,000 to 96,000 people in the
country or 0.1 percent of the adult population.
Recent studies,40 further indicate that there is a rise in
HIV/AIDS and STI cases in the 'high risk groups'
with concentrated epidemics beginning in
48
Esculapio - Volume 07, Issue 04, October-December 2011
as the Department for International Development
(DFID) and Canadian International Development
42
Agency (Canadian CIDA). The contract for the
Enhanced Program was signed in 2002; however, the
funds were released to the provinces only in 2004.
Pakistan still has a window of opportunity to act
decisively to prevent the spread of HIV. Although
the estimated HIV burden is still low around 0.1
percent of the adult populationthe country is facing
a concentrated epidemic among injecting drug users
(IDUs) with HIV
prevalence above 5 percent among IDUs in three of
the four provinces. Given linkages between IDUs and
other high-risk populations including male and
female sex workers, Pakistan needs to scale up
targeted intervention urgently to prevent rapid
increase in HIV among vulnerable groups.
2013. A draft national AIDS policy and HIV and
AIDS Law (both recommending the formation of a
National AIDS Council) have been prepared by the
National AIDS Control Programme and will be
presented to the national cabinet and parliament.
Approval of the policy and law would be an
important step towards the multi-sectoral dimension
of the national response.
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Issues and challenges: Priority areas.
Vulnerable and High-risk Groups
¦ Expand knowledge, access, and coverage of
vulnerable populationsparticularly in large citiesto
a package of high impact services, through
combined efforts of the government and NGOs.
¦
Implement harm-reduction initiatives for IDUs
and safe sex practices for sex workers.
¦ Make effective and affordable STD services
available for high-risk groups and the general
population.
General Awareness and Behavioral Change
Undertake behavioral change communications with
the following behavioral objectives:
(I) Use of condoms with non-regular sexual partners;
(Ii) use of STI treatment services when symptoms
are present and knowledge of the link between
STIs and HIV;
(iii) use of sterile syringes for all injections;
(iv) reduction in the number of injections received;
(v) voluntary blood donation (particularly among the
age group 18 to 30);
(vi) use of blood for transfusion only if it has been
screened for HIV; and
(vii) display of tolerant and caring behaviors towards
people living with HIV and members of
vulnerable populations.
Increase interventions among youth, police, soldiers,
and migrant laborers.
Blood and Blood Product Safety
¦
Ensure mandatory screening of blood and blood
products in the public and private sectors for all
major blood-borne infections.
¦
Conduct education campaigns to promote
voluntary blood donation.
¦
Develop Quality Assurance Systems for public
and private blood banks to ensure that all blood
is properly screened for HIV and Hepatitis B.
Surveillance and Research
¦
Strengthen and expand the surveillance and
monitoring system.
¦ Implement a second-generation HIV surveillance
National Response To HIV/Aids
Co
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Government: Pakistan's Federal Ministry of Health
initiated a National AIDS Prevention and Control
Program (NACP) in 1987. In its early stages, the
program was focused on diagnosis of cases that came
to hospitals, but progressively began to shift toward a
community focus. Its objectives are the prevention of
HIV transmission, safe blood transfusions, reduction
of STI transmission, establishment of surveillance,
training of health staff, research and behavioral
studies, and development of program management.
The NACP has been included as part of the
government's general health program, with support
from various external donors. As the government has
indicated, more needs to be done. For example, focus
on reducing the exposure of high-risk groups is
urgently required as is increasing the service coverage
of key populations (injecting drug users, female sex
workers, men who have sex with men, and prison
inmates).
Other priority areas that require attention include
improving access to quality treatment and care,
strengthening the monitoring and evaluation system,
continued advocacy with policy makers and other
influential groups, and effective coordination with
key agencies including police, jail authorities, and the
Ministry of Law and of Narcotics Control.
In early 2001, the Government of Pakistan, through a
broad consultative process, developed a national
HIV/AIDS Strategic Framework that set out the
strategies and priorities for effective control of the
epidemic. The government has finalized costed
action plans for the next phase of the federal and
provincial Programs covering the period from 2009-
49
Esculapio - Volume 07, Issue 04, October-December 2011
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pk
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World Bank response
Future
The use of combinations of antiretroviral drugs has
proven remarkably effective in controlling the
progression of HIV disease and prolonging survival,
but these benefits can be compromised by the
development of drug resistance. 43 Efforts to produce
universally available against HIV have so far yielded
disappointing results in phase III trials.44
Co
References
Department of Medicine
Sheikh Zaid Hosptial ,Lahore
theesculapio@hotmail.com
Www.sims.edu.pk/esculapio.html
py
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gh
ts
@
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The World Bank is the largest financer of HIV/AIDS
programs in Pakistan. It assisted the government's
HIV/AIDS efforts through funding the second
Social Action Program (1998-2003). In addition, the
World Bank is working with the government and
other development partners (CIDA, DFID, USAID,
UN agencies) to support the government's program
through the HIV/AIDS Prevention Project. The
Bank is providing US$37.1 million, 75 percent of
which is a no-interest credit and 25 percent of which
is grant money. The project is supporting HIV
prevention services to most at-risk groups, mass
media campaigns aimed at raising awareness and
reducing stigma, promoting safe blood transfusion,
and building management and institutional capacity.
The implementation of targeted intervention has
made encouraging progress with expanding coverage
of an injecting drug users program in Punjab;
implementation of service delivery packages for male
and female sex workers in Sindh, Punjab, and NWFP;
jail inmates in Sindh; and truckers nationwide. The
data from three rounds of surveillance indicate that
HIV prevention services are making a difference as
reflected in a reduction in risk behaviors most notably
among injecting drug users. At the same time the
current coverage of these interventions is limited,
covering barely 15-20 percent of the most at-risk
groups of injecting drug users and sex workers. The
most important issue relates to mobilizing resources
and capacity for scaling up services to the high-risk
populations. Significant challenges also relate to
building capacity of the federal and provincial
programs and of the implementing NGOs.
The Bank is committed to supporting the
Government's Program over the next phase, focusing
particularly on increasing service coverage of most
at-risk groups in all major urban centers, improving
access and quality of treatment and care, and
strengthening the monitoring and evaluation system.
A three-year antiretroviral treatment programme was
started in Pakistan in 2006, which included import of
drugs from India. The programme will be available to
8000 infected people at public sector hospitals. Cost
of generic treatment was $300-500 a patient a year.
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Implement a second-generation HIV surveillance
that tracks sero-prevalence and changes in HIVrelated behaviors, including the spread of STIs
and HIV, sexual attitudes and behaviors, and
healthcare-seeking behaviors related to STIs.
Building Management Capacity
¦ Continue to build management capacity within
provincial programs and local NGOs to ensure
evidence-based program implementation.
¦
Identify gaps in existing programs and continue
phased expansion of interventions.
1. Clinical review: ABC of AIDS,
Development of the epidemic by
Michael W Adler BMJ
2001;322:1226-1229
2. 2007 Update on the global AIDS
epidemic by UN AIDS (Joint
United Nations Programme on
HIV/AIDS), UNAIDS/07. 27E
/JC1322E (English original,
December 2007)
3. World Bank Report 2007 by
Shahzad Sharjeel and Mr. Erik
Nora available at
http://siteresources.worldbank.
org/INTSAREGTOPHIVAID
S/Resources/HIV-AIDS-briefAugust07-PK.pdf
4. Centres for Disease Control and
Prevention (1996). "U.S. HIV and
AIDS cases reported through
December 1996" HIV/AIDS
Surveillance Report 8 (2): 1-40.
5. Progress on Global Access to
HIV Antiretroviral Therapy: a
Report on “3 by 5” and Beyond ,
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Antiretroviral Therapy: a Report
on “3 by 5” and beyond, ISBN 924
1594136
6. Munch, J., Rajan, D., Schindler,
50
M., Specht, A., Rucker, E.,
Novembre, F. J., Nerrienet, E.,
Muller-Trutwin, M. C., Peeters,
M., Hahn, B. H., Kirchhoff, F.
(2007). Nef-Mediated
Enhancement of Virion
Infectivity and Stimulation of
Viral Replication Are
Fundamental Properties of
Primate Lentiviruses. J. Virol. 81:
13852-13864
7. A. R. Lifson , Do alternate
modes for transmission of
human immunodeficiency virus
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Medical News
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(Reuters) Feb 17 - Hopes were raised slightly on
Friday that U.S. health regulators could approve a
weight-loss pill for the first time in 13 years, after
government reviewers did not flag fresh safety risks
for an experimental obesity drug from Vivus Inc.
Food and Drug Administration staff said in
documents posted online that the drug Qnexa did
help people lose weight, though they reiterated
concerns about the risk of birth defects and heart
problems.
The FDA rejected Qnexa in 2010 because of safety
problems, and on Friday agency staff still seemed
skeptical about the drug's long-term health effects,
especially on the heart.
FDA staff will ask a panel of outside experts next
Wednesday to consider whether the benefits of
Qnexa for obese patients outweigh its safety risks, or
if the company needs to do more studies.
Obesity, a leading cause of diabetes, heart disease and
other serious health problems, has reached epidemic
proportions in the United States, with about a third of
the population affected.
But the FDA has set a high approval bar for weight
loss drugs because such a large portion of the general
population is likely to want to take them. The agency
has not approved a new obesity drug since 1999.
Qnexa is one of three obesity pills up for a second
round of consideration from the FDA.
"Ultimately, only a long-term, cardiovascular
outcome trial can define the effect of (Qnexa)
treatment on risk for major adverse cardiovascular
events in an obese at-risk population," FDA reviewers
said about Qnexa.
The FDA staff said they would also ask the advisers
whether Vivus needs to do a heart-focused study of
Qnexa before it is approved. The FDA will make its
final decision by April 17.
FDA staff said patients taking Qnexa during a clinical
trial had lost more weight, and kept it off for longer,
than those taking a placebo, or sugar pill. The Qnexa
patients also had lower levels of problems associated
with obesity, such as issues with blood pressure and
blood sugar.
However, the FDA staff said patients taking the drug
had more safety problems, including memory loss
and higher heart rates, than those on a placebo, and
some of these problems could get worse over time.
They also said exposure to one of the ingredients in
Qnexa has been linked to a higher rate of birth
defects in other studies.
REAL-WORLD PROBLEMS
Qnexa is a combination of appetite suppressant
phentermine and anti-seizure drug topiramate.
A company study showed topiramate caused a higher
rate of oral clefts in infants of women taking the drug
during pregnancy, and the company said it would limit
Qnexa to women who are not pregnant.
Vivus resubmitted its application to the FDA in
October with more data and proposed to limit the
drug to only women who cannot have children. In
January, the company broadened the label to just limit
pregnant women from taking it, in response to an
FDA request.
Jason Butler, an analyst at JMP Securities, said the
FDA's request to allow non-pregnant women to take
the drug was a positive sign.
"The FDA is saying ... it's a small signal of risk, but it's
not so great that we have to stop people using it,"
Butler said, adding he expected heart issues to be a
greater concern.
However, in its review on Friday, the FDA staff said
limiting the drug to nonpregnant women might be
difficult in the real world, especially since 34 women
got pregnant during the clinical trial.
Vivus is not the only company vying to get an obesity
drug on the market.
Arena Pharmaceuticals and Orexigen Therapeutics
have been pitching their own fat-fighters again to the
FDA after rejections.
In February, Orexigen agreed with the FDA on the
design of a 10,000-patient heart-safety trial required
for the approval of its Contrave drug.
The FDA is also set to review Arena's lorcaserin by
June 27, after rejecting it in October 2010 because of
a potential cancer risk.
Drugmakers have struggled for years to develop
weight-loss drugs that are both effective and safe.
Back in 1997, the infamous diet drug "fen-phen" was
pulled from the market after reports of fatal heartvalve problems in some users. Another diet pill,
Meridia, was pulled from the U.S. market in 2010 after
being linked to heart problems.
The only prescription obesity drug currently
approved for long-term use is Roche Holding AG's
Xenical, which got the FDA's nod in 1999.
GlaxoSmithKline markets a lower-dose, over-thecounter version called Alli. But both have their own
problems, as they can cause serious liver problems,
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Modest Hope for FDA Approval of Novel
Obesity Drug
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February 17, 2012 Researchers have conducted the
first-in-human clinical trial of an implantable,
wirelessly controlled microchip that can be
programmed to deliver medication to patients with
osteoporosis.
Robert Farra, from MicroCHIPS Inc, Waltham,
Massachusetts, and colleagues report the results of
their study in an article published online February 16
in Science Translational Medicine. The study was funded
by Micro CHIPS Inc.
"This study has demonstrated the clinical viability of
the microchip-based implantable drug delivery
device," the authors write.
Human parathyroid hormone fragment (1-34)
[hPTH (1-34)], called teriparatide (FORSTEO Eli
Lilly), promotes bone formation and is currently the
only approved anabolic treatment for osteoporosis.
However, it requires daily injections, and long-term
compliance is low.
To determine whether delivery of hPTH(1-34) via an
implanted microchip is safe and has an adequate
pharmacokinetic profile, the researchers enrolled 7
postmenopausal women with osteoporosis in the
pilot trial. Each woman received a series of 19
microchip-administered 20-μg doses of hPTH(1-34),
followed by a series of 19 doses of 20 to 40 μg
teriparatide. The 40-μg doses were given in 2
consecutive doses of 20 μg teriparatide by manufacturer's injector pen, injected without removing the
pen between doses.
Clinicians implanted the microchip in each patient,
using local anesthetic. Patients received the first
microchip-administered dose 8 weeks later to allow
time for a tissue capsule to fully develop around the
implant. Doses were then automatically given every
24 hours, for a total of 19 doses, on days 57 to 75. A
final dose was given on day 84. On days 91 and 96,
teriparatide 20 μg was subcutaneously injected for
comparison. The microchip was removed on day 103,
with 2 postimplant doses of teriparatide 40 μg (2 × 20
μg) given by subcutaneous injection on days 131 and
138.
To assess pharmacokinetic parameters and bone
formation markers, the team collected blood samples
from patients on days 60, 65, 70, and 84 after
microchip dosing, and on days 91, 96, 131, and 136
after teriparatide injections. The pharmacokinetic
samples were drawn within 5 minutes of drug
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Osteoporosis Drug Delivery via Wireless
Microchip
administration. Blood was then obtained at 5, 10, 20,
30, 45, 60, 120, 240, and 360 minutes after the dose,
for hPTH (1-34) analysis.
Blood samples obtained at -5, 60, 120, 240, and 360
minutes were used to determine serum calcium
kinetics.
Pharmacokinetic profiles were comparable between
the 2 delivery methods, although they were steadier
with microchip delivery. The results suggest this
technology could help overcome problems
associated with poor compliance that some patients
experience becuse of injection aversion and difficulty
remembering to take medication.
The team also used serum type 1 collagen propeptide
(P1NP) and type 1 collagenolysis fragment (CTX)
measurements to identify changes in bone formation
and bone resorption. During the period of daily
dosing with the microchip, serum P1NP levels
increased progressively, with a mean increase between
the first and fourteenth days of dosing of 143% (P =
.01, pairwise t-test). "An increase in P1NP is
consistent with anabolic increase in bone formation,
which is essential to increasing bone mineral density,"
the authors write.
P1NP levels began to decrease after completion of
the daily microchip dosing. CTX levels remained
normal and steady during the hPTH(1-34) dosing
period.
The microchip and drug were biocompatible and did
not cause any adverse immune response. Tissue
obtained at the time of explantation from the tissue
capsule indicated good healing without inflammation.
In addition, patients responded to questionnaires
intermittently during the study. Most patients said
they would use an implantable device again, although
there was a slight drop in enthusiasm between the first
questionnaire on day 54 and questionnaires answered
on days 84 to 91.
In an accompanying editorial, John T. Watson, PhD,
from the von Liebig Center for Entrepreneurism and
Technology Advancement at the University of
California, San Diego, writes that this study is a good
example of how the scientific method and the
engineering design method must work in harmony.
"To translate a new medical product or process to
clinical use, there are several essential parallel
pathways: funding/financing; research and
development; regulation and payment; design
controls; clinical trials; facilities and manufacturing;
intellectual property; and marketing and sales," Dr.
Watson writes.
"Experience suggests that this technology must still
cu
uncontrolled bowel movements and gas.
Reuters Health Information © 2012
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NEW YORK (Reuters Health) Feb 06 - Infection
with Helicobacter pylori more than doubled the risk
of diabetes in a new study of Latino adults in
California.
The results show that H. pylori "is strongly related to
predicting type 2 diabetes," said Dr. Allison Aiello
from the University of Michigan in Ann Arbor, the
senior researcher on the study.
Earlier studies looking at the relationship between H.
pylori infection and diabetes have had inconsistent
results. But Dr. Aiello and her colleagues point out in
their report online January 25 in Diabetes Care that
previous research has only been snapshots in time of
who had diabetes, who had the infection and who
didn't.
To try to get a better fix on whether one condition
might cause the other, the group tracked nearly 800
people for a decade. None of them had type 2
diabetes at baseline. Over time, 144 people developed
the disease, and 97% of those individuals had tested
positive for H. pylori at the start of the study.
By contrast, 91% of people who didn't develop
diabetes had tested positive for H. pylori.
After the researchers took into account factors such
as vascular disease, smoking and being overweight,
they found that the risk of developing diabetes was
2.7 times higher among the group of people who had
the infection.
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H. pylori Tied to Higher Diabetes Risk
The Centers for Disease Control and Prevention says
that about two-thirds of people worldwide have been
infected with H. pylori, but most never experience
any symptoms.
The fact that the researchers followed people over
time and showed that the diabetes cases developed
after people were infected with H. pylori gives "more
credence to a potential causal relationship," they
wrote.
Dr. Alain Bertoni, a professor at Wake Forest Baptist
Medical Center who was not involved in the study,
agreed that "the results are suggestive that this is a
causal relationship," but offered other possibilities
that could explain the findings.
"It is possible that some factor not measured (a
confounder) that is associated with NOT being H.
pylori positive...is actually a protective factor, rather
than H. pylori is causing diabetes," Dr. Bertoni wrote
in an email to Reuters Health. "For example, the
authors did not consider physical activity."
The researchers did find that if they accounted for
people who were taking antacids or antibiotics to treat
the infection it did not alter their results.
They also did not see a similar link between other
infections -- namely, herpes, varicella virus,
cytomegalovirus, and the bacterium Toxoplasma
gondii -- and diabetes.
It's not clear why H. pylori and diabetes are related,
though Dr. Aiello said there is speculation that the
bacteria could alter the conditions in the gut or
promote inflammation that might contribute to
diabetes.
As for the extremely high rate of infection among the
people in her study -- more than 90% -- she said, "It's
pretty amazing, especially given that we have
treatments for H. pylori."
It will be important for future studies to show if H.
pylori does indeed have an influence on diabetes, said
Dr. Aiello, because the infection can be treated.
SOURCE: http://bit.ly/zb6N5G Diabetes Care
2012.
cu
negotiate several years of translational hurdles if, in
fact, it becomes part of our clinical armamentarium,"
he concludes. The researchers also presented the
study results at the annual meeting of the American
Association for the Advancement of Science in
Vancouver, British Columbia.
Farra and 2 coauthors are employed by MicroCHIPS Inc; one
coauthor is a board member of MicroCHIPS Inc; 2 coauthors
are paid consultants of MicroCHIPS Inc; and several
coauthors hold patents in various aspects of the microchip. Dr.
Watson has disclosed no relevant financial relationships.
Sci Transl Med. Published online February 16, 2012.
Guidelines
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NICE Guidelines for the treatment of Hypertension 2011
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Step 3 treatment
•
Before considering step 3 treatment, review
medication to ensure step 2 treatment is at optimal or
best tolerated doses.
•
If treatment with three drugs is required, the
combination of ACE inhibitor (or angiotensinII receptor blocker), calcium-channel blocker
and thiazide-like diuretic should be used.
Step 4 treatment
•
Regard clinic blood pressure that remains
higher than 140/90 mmHg after treatment with the
optimal or best tolerated doses of an ACE inhibitor
or an ARB plus a CCB plus a diuretic as resistant
hypertension, and consider adding a fourth
antihypertensive drug and/or seeking expert advice.
• For treatment of resistant hypertension at step 4:
• Consider further diuretic therapy with low-dose
•
•
•
•
spironolactone4 (25 mg once daily) if the blood
potassium level is 4.5 mmol/l or lower. Use
particular caution in people with a reduced
estimated glomerular filtration rate because they
have an increased risk of hyperkalaemia.
Consider higher-dose thiazide-like diuretic
treatment if the blood potassium level is higher
than 4.5 mmol/l.
When using further diuretic therapy for resistant
hypertension at step 4, monitor blood sodium
and potassium and renal function within 1 month
and repeat as required thereafter.
If further diuretic therapy for resistant
hypertension at step 4 is not tolerated, or is
contraindicated or ineffective, consider an
alpha- or beta-blocker.
If blood pressure remains uncontrolled with
thiazide-like diuretic. (4) At the time of publication
(August 2011), spironolactone did not have a UK
marketing authorisation for this indication. Informed
consent should be obtained and documented. (5)
Consider an alpha- or beta-blocker if further diuretic
therapy is not tolerated, or is contraindicated or
ineffective.
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the optimal or maximum tolerated doses of
four drugs, seek expert advice if it has not yet
been obtained.
Footnotes
(1) Choose a low-cost ARB. (2) A CCB is preferred
but consider a thiazide-like diuretic if a CCB is not
tolerated or the person has oedema, evidence of heart
failure or a high risk of heart failure. (3) Consider a
4
low dose of spironolactone or higher doses of a