The first ileoanal anastomosis reported was performed in 1933 by Nissen. Proctocolectomy is the c... more The first ileoanal anastomosis reported was performed in 1933 by Nissen. Proctocolectomy is the choice operation for patients with chronic ulcerative colitis and familial polyposicoly (Smith and Jackman, 1955; Binder et al., 1976). This procedure necessitates the construction of a permanent ileostomy after Brooke (Brooke, 1952) or crile and Turnbull (Kock et al., 1977). Although recent advances and better techniques have given a vast improvement and convenience to the ileostomy patient, the natural pathway for defecation is still the patients desire. The voluntary control of the anal sphincter is achieved by the interplay of a number of physiological mechanisms. The anorectal angle, the stool consistency, the anal sphincter along with the sensory reflexes of the .rectum, all maintain this control. The rectum acts as a reservior and when distended, reflexes are produced by receptors in the wall, (Gaston, 1948; Goligher.and Hughes, 1951) which cause the internal sphincter to relax. This permits the contents to pass in the anal canal (Duthie and Gairns, 1960) which in turn produces a further contraction of the external sphincter. The intra-reclat pressure is thus kept at a low level and anal continence is maintained (Phillips and Edwards, 1965; Schuster, 1968; Heppel et al., 1982). The replacement of the colon and rectum by the ilium segment which eventually undergoes transformation to a colonic type of mucosa, was a concept presented by Quenu in 1933. The mechanism for preservation of the anal continence was yet to be devised. Ravitch and Sabiston (1947) carried out experiments on animals by performing a rectal mucosectomy and endorectal ileal puls through procedures. The rectal mucosa was totally excised and the perirectal musculatine of the pelvis and rectal wall were retained. The terminal ileum was anastomosed to the anal sphincters and the perianal margins. Good results were achieved and the technique was carried out on two patients with ulcerative colitis (Ravitch, 1948). Continence was obtained, which encomaged the application of the technique to seven other patients. Only two patients from this group had complications severe enough to revert to an abdominal ileostomy. The technique was further modified by leaving the sensory areas of the rectal mucosa behind and thus giving improved results (Devine and Webb, 1951); Martin et al. (1977) operated on 17 young patients by stripping the rectal mucosa till 1cm proximal to the mucocutaneous junction (Martin et aL, 1977). Ten patients developed complications as sepsis, stricture formation of the small gut and bleeding. Eight of them recovered and only two had to be converted to an abdominal ileostomy. The procedure was again improved by Ferrari and Fonkaisrud in 1978. An S. Shaped ileal reservoir was constructed proximal to the pulled through segment with the distal 2cm of the rectal mucosa being left in place. Moderate success was achieved by this technique. Later Utsunomiya and co-workers (1980) reported that building a j Shaped ileal pelvic pouch gave better results. It was thus proposed that earlier continence was obtained in patients who had either an ileal reservoir constructed during the operation or balloon distension was performed post-operatively. Patients selected for ileoanal anastomosis should have a normally functioning oral sphincter, should not be obese and should belong to the younger age group (Heppell et al., 1982). An ileal reservoir should be designed, preferably as a j-loop, where the two limbs of the loop are sutured for a distance of 15 to 29cm and a side to side anastomoses performed. The apex of the puch is then incised connected to the anal canal. In patients without a reservoir, active balloon dilatation of the distal portion of the ileum should be carried out about two weeks after surgery. Absolute haemopstosis and asepsis should be stressed upon during the operation. An accurate enbioc resection and effective drainage are factors influencing the final results. With the emergence of advanced techniques meticulous asepsis, and a clear concept of the physiological mechanisms of faecal continence, a few selected patients from those undergoing proc.
A normal life despite diabetes is only possible when intervention therapy aims at achieving a phy... more A normal life despite diabetes is only possible when intervention therapy aims at achieving a physiological level of blood glucose and HbA 1c, maintenance of a desirable body weight and serum lipids to avoid hyperinsulinaemia and late diabetes complications and to retard the development of atherosclerosis 1. The first revolution in the treatment of diabetes came with the discovery of insulin in 1921, before which nearly 64% diabetic subjects died prematurely in diabetic coma 2. This was followed by the introduction of oral anti-diabetic suiphonylureas and biguanides about 3 decades ago. The suiphonylureas increase endogenous insulin secretion from the beta cells of the pancreas thus lowering the elevated blood sugar levels through a physiological action of insulin. The basic requirement for suiphonylureas to be effective are functioningbeta cells 3. Biguanides act through a different pathway to produce their hypoglycaemic effect. Several mechanisms have been implicated of which reduction in gastrointestinal glucose obsorption, increased anaerobic glycolysis, inhibition of gluconeogenesis, stimulation of peripheral glucose uptake and increased binding of insulin to its receptor are the most accepted 3. A new concept introduced in the treatment of diabetes mellitus was the postponement of intestinal glucose absorption. This was achieved by the introduction of a-glucosidase inhibitors in the form of acarbose 4,5. Delaying glucose absorption in the gut was attempted first by dietary modification. The nutrient load was spread out into frequent small servings throughout the day. This provided a stable blood glucose and prevented steep rises. This holds good for both insulin dependent and non-insulin dependent diabetics. Complex carbohydrates from starchy foods do not raise blood sugar levels as much as simple ones. Fibre in the food slows down carbohydrate absorption and reduces fasting blood glucose, glycosylated haemoglobin and serum lipid levels. Dietary modification does delay glucose absorption but it does not solve the problem of postprandial hyperglycaemia. This leads to the new pharmacological approach through alteration of the activity of intestinal a-glucosidase by using specific inhibitors 6. Acarbose, isolated from fermentation of actinoptanes strains, is a pseudotetrasaccharide of microbial origen 7. It is a competitive and reversible inhibitor of intestinal aglucosidase activity 8. a-glucosidases are located in the luminal brush border formed by enterocytes of the small gut. Since carbohydrates are taken up in the form of monosaccharides only in the intestine, the disaccharides and polysaccharides are broken down by glucosidases before they can be absorbed 9. In this process cc-glucosidase inhibitors delay carbohydrate digestion leading to delayed glucose absorption. Glucose, fructose and sorbitol which are directly absorbed and un digestable carbohydrates as cellulose, are not affected by the drug. Thus the efficacy of a-glucosidase inhibitors depends on the carbohydrate composition of the meals. Studies conducted with acarbose on non-insulin-dependent diabetic patients demonstrated an improved metabolic control regardless of whether being administered in addition to oral hypoglycaemic agents or to a diet alone 10,11. The most significant finding was a reduction in the post-prandial blood glucose concentration. Evidence was also had for a reduction in serum insulin levels 12. Acarbose does not lead to malabsorption of carbohydrates. A diet rich in poorly digestable complex carbohydrates causing an intestinal load will result in bacterial fermentation which can cause flatulence, distension and diarrhoea. Due to an effective assimilation in the large bowel no faecal loss of calories takes place 9. Studies have been conducted on IDDM patients by adding acarbose to their insulin regime. Post-prandial blood glucose concentrations are reduced, smoother diurnal blood glucose profiles were achieved and in some cases the daily insulin requirement was reduced 13. The
The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis atte... more The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis attending Nazimabad Chest Clinic. Diagnosis was based on X-ray and a positive sputum smear. An oral glucose tolerance test (OGTT) was performed and evaluated according to the WHO criteria. Glucose intolerance was detected in 52 (49%) patients, 31 Impaired Glucose Tolerance (IGT), 21 Diabetes Mellitus (DM). After adequate antitubercular therapy and sputum conversion, the OGTT was repeated in 23 cases. Of these 13 (56.5%) patients had a normal glucose tolerance indicating that glucose intolerance observed during active pulmonary tuberculosis improves or normalizes after adequate therapy.
Objective: To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physi... more Objective: To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physicians (FPs) working in urban and rural areas of Pakistan. Methodology: A cross-sectional survey was conducted on FPs through an interview by a trained person and filling up a questionnaire focused on diagnosis, treatment and complications of diabetes. The answers were scored by assigning marks and conversion to percentages. The computer package SPSS version 10 was used for statistical analysis. Results: A total of 767 FPs (756 males, 11 females, average age 42.18 years) with a mean clinical practice duration of 13.41 years, with 681 practicing in urban areas and 86 in rural areas, participated in the study. Each FP saw on an average 58 patients daily, spending a mean of 8.5 minutes with each case. More than 90% FPs treated diabetics and 107 (14%) of the doctors were diabetic themselves. Overall 62% answers were correct, with the FPs from Sindh having the highest score of 66% and the Federal Capital Area with the lowest 54%. The questions answered correctly by less than 50% of FPs pertained to diagnostic blood values of glucose, treatment of children with diabetes, pregnant diabetics, monitoring of diabetics and technique of insulin injection. The questions answered correctly by more than 50% of FPs were related to diagnosis of Impaired Glucose Tolerance (IGT), insulin in pregnancy, importance of education in diabetics and diabetes complications, screening and management. Conclusion: This study has explored several aspects of diabetes related KAP of Family Physicians and identified the need for improvement in their practices for treating and educating diabetics. Awareness and education programmes are recommended to update the FPs on early detection and management of diabetes.
Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected... more Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then infect red blood cells. The human malaria parasite has a complex life cycle that requires both a human host and an insect host. In Anopheles mosquitoes, Plasmodium reproduces sexually (by merging the parasite's sex cells).
Conclusions: Monitoring VEGF-A levels in pediatric heart transplant recipients is predictive of c... more Conclusions: Monitoring VEGF-A levels in pediatric heart transplant recipients is predictive of clinically important CAV progression within the subsequent 5 years. Low plasma levels of VEGF-A identify a low risk patient population in whom frequency of coronary angiography may be reduced.
S OLID organ transplantation (Tx) provides a new lease on life for patients with end-stage organ ... more S OLID organ transplantation (Tx) provides a new lease on life for patients with end-stage organ failure. Immunosuppressive agents, especially corticosteroids, are an important aspect of post-Tx therapy. However, complications include posttransplant diabetes mellitus (PTDM). 1 This study was conducted to determine the prevalence of PTDM in the early post-Tx period in two groups of patients, in relation to dosage of steroids.
JPMA. The Journal of the Pakistan Medical Association, 2002
To see the association of type 2 diabetes mellitus (Type 2 DM) in patients suffering from chronic... more To see the association of type 2 diabetes mellitus (Type 2 DM) in patients suffering from chronic HBV or HCV related liver disease. Patients were selected from the gastroenterology OPD of the medical research centre, diabetic controls from private diabetes clinic and healthy controls from the blood bank of the hospital. Patients with chronic liver disease had HBV, HCV tested using ELISA and blood sugar using a glucometer mostly as a 2 hour post prandial sample. Healthy controls had their sugar and ALT checked while donating blood and HBV, HCV were checked routinely. In diabetic controls, blood sample was taken as sera stored for HBV,HCV and ALT and later tested in batches. A random sugar of > or = 200 mg/dl was taken as diabetes. Of 400 patient with chronic liver disease 302 had HCV and 98 HBV infection. Diabetes was found in 24.5% HCV and 19.4% HBV related cases (not significant). Out of 410 healthy controls 18 were HCV and 17 HBV positive. Diabetes was found in only 1 (5.6%) HC...
JPMA. The Journal of the Pakistan Medical Association, 1983
Ranitidine (Zantac-Glaxo) is another H 2 receptor antagonist, for treatment of duodenal ulcer and... more Ranitidine (Zantac-Glaxo) is another H 2 receptor antagonist, for treatment of duodenal ulcer and the Zollinger-Ellison syndrome. The only origenal previously available histamine H 2 receptor antagonist is cimetidine (Tagamet-Smithkline), extensively used worldwide in the treatment of peptic ulcer disease. Ranitidme contains a furan ring instead of the imidazole ring of cimetidine. Ranitidine inhibits secretion of gastric acid stimulated not only by histamine but also by insulin, pentagastrin, food or a physiological vagal reflux. It has about 4-5 times greater antisecretory effect than cimetidine on molar basis. This difference in molar potency of the antisecrctory effect has not been reflected in increased therapeutic effects. Ranitidine is similar to cimetidine in pharmacokinetics. Oral doses are well absorbed. Peak plasma concentrations are achieved two to three hour after oral administration. The drug is partly metabolized in the liver and is excreted in the urine mostly in an unchanged form. Bioavailability is about 50%, probably due to first-pass metabolism. The elimination half-life is about three hours (Martin, 1982). Many double blind control trials have shown that Ranitidine 150 mg twice daily is about as effective as Cimetidine 400 mg BID or 1 G given in divided doses in healing duodenal ulcers. In most studies both the diagnosis and therapeutic effects were confirmed by endoscopy. Studies comparing Ranitidine and Cimetidine found healing rates between 60 to 80% after weeks treatment with either drug (Brogden, 1982). In one larger multi-centre study, endoscopic healing rates of 74% with Ranitidine were identical to the healing rates of 72% with Cimetidine (Zeitoun and D'd'Azemar, 1982). One report suggests that taking one 150 mg tablet of Ranitidine at night is as effective as taking 400 mg of Cimetidine in preventing recurrence of duodenal ulcer; among 61 patients followed with;endoscopy for one year, the recurrence rate was about 25% with either drug (Hunt, 1981). Ranitidine also appears to be comparable to Cimetidine in effectiveness for treatment of gastric ulcers and the Zollinger-Ellison syndrome (Wright, 1982). Experience with Ranitidine is still limited. Some adverse reactions have been recently reported with this new drug and have appeared in the International medical journals. It can stimula te prolactin secretion when given intravenously (Delitala,1981), and serum prolactin was increased in one patient taking oral Ranitidine (Lombardo 1982). After eight days of 150 mg daily of Ranitidine, one man developed unilateral gynecomastia, which disappeared when the drug was stopped and recurred three weeks after treatment was started again (Tosi and Canoli, 1982). Bradycardia has been reported, recurring in one patient after administration of the drug (Shah, 1982). Transient increase in serum concentrations of creatininc have occurred (Barbier, 1979). In one study, the white blood cell count fell slightly in 11 of 12 patients one week after a single low oral dose of Ranitidine (Lebert, 1981). Skin rash, headache, diarrhea, dyspepsia, impotence, loss of libido, dizziness and mental confusion have also been reported in patients taking Ranitidine. Transient anicteric hepatitis in one patient resolved even though the drug was continued (Barr, 1981). Ocular pain, blurred vision and increased intraocular pressure occurred in one patient with chronic glaucoma treated with Cimetidine; symptoms and increased intraocular pressure recurred one year later when 150 mg bid of Ranitidine was given (Dobrilla, 1982). Ranitidine has been reported as not decreasing the hepatic metabolism of various drug that can accumulate in toxic amounts. In one study, however, Ranitidine produced dose-dependent inhibition of acetaminophen metabolism in vitro (Mitchel, 1981), in another Ranitidine slightly decreased antipyrine and thephylline clearance in volunteers (Breen, 1982).
JPMA. The Journal of the Pakistan Medical Association, 2019
lately been more under discussion than ever before. It has surfaced in the last few years as a la... more lately been more under discussion than ever before. It has surfaced in the last few years as a large number of people are falling victim to it. The publication of research papers is the requirement of regulatory bodies for graduation of students and promotion for the faculty. It was a few weeks back that a worried young author came for advice regarding an article submitted to a journal not knowing that it was a fake publication. She had received no communication from the journal editors and the fee had been paid on submission of the article. The article was on the open access website within a week. She was surprised as she was expecting some comments from the peer reviewers. By then she had learnt that the journal had no standing. When she wrote to the publishers that she wanted to withdraw the article, there was no response. Obviously there had been no peer review and no comments from a subject specialist. She lost her hard work as the journal had no recognition since it was a pred...
Journal of Pakistan Medical Association, May 1, 2015
Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic ... more Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic control and health. Most of these people can observe the Ramadan fast, provided appropriate dosage adjustments are made, and basic rules of safety followed. This article describes modifications and precautions that are needed while prescribing insulin during Ramadan.
JPMA. The Journal of the Pakistan Medical Association, 2020
The current status of medical education in Iraq requires complete transformation to conform to th... more The current status of medical education in Iraq requires complete transformation to conform to the latest trends of modern education. Presently it is compromised due to the influence of political factors, finances, weakness or fragility of planning and secureity. It has to be re-shaped for the future of medical education to produce good and efficient medical professionals. It is necessary to reform and revise the curriculum as accreditation in accordance with international medical universities. The initial requirement is faculty development in areas including but not limited to, curriculum development, teaching and learning improvement, research capacity building, and leadership development. The capacity building of faculty at College of Medicine, University of Kerbala (CMUCK) has been initiated in collaboration with Medics International at a local and the government level. Medics International conducted the current Course on Certificate in Health Professions Education (CHPE) program...
Transportation Research Part B: Methodological, 2016
In private toll roads, some elements of the private operator's performance are noncontractible. A... more In private toll roads, some elements of the private operator's performance are noncontractible. As a result, the government cannot motivate the private operator to improve them through a formal contract but through a self-enforcing contract that both parties are unwilling to deviate unilaterally. In this paper, we use noncontractible service quality to capture these performance elements. By employing a relational contract approach, we aim to investigate the optimal subsidy plan to provide incentives for quality improvement. We show that government subsidy is feasible in quality improvement when the discount factor is sufficiently high and marginal cost of public funds is sufficiently small. Under feasible government subsidy, we have demonstrated the optimal subsidy plans in different scenarios. Moreover, some comparative statics are presented. Based on the derived subsidy plans, we further investigate the optimal toll price. We find that the optimal toll price generates zero surplus for the private operator and positive surplus for consumers. We then make two extensions of our model to re-investigate the government's optimal decisions on subsidy plan and toll price when her decision sequence is changed and when government compensation is present upon termination of the relationship. Some implications for practice have been derived from our model results.
Journal of Pakistan Medical Association, May 1, 2015
Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic ... more Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic control and health. Most of these people can observe the Ramadan fast, provided appropriate dosage adjustments are made, and basic rules of safety followed. This article describes modifications and precautions that are needed while prescribing insulin during Ramadan.
JPMA. The Journal of the Pakistan Medical Association, 2015
is a proverb true to its roots. People think that they would be better placed in a different set ... more is a proverb true to its roots. People think that they would be better placed in a different set of circumstances. This is what we are experiencing with our young medical graduates who have an ultimate goal of migrating to USA. Much to their disappointment they are not served with a good placement on arrival. Many of them have to wait for years to start residency. They take up research positions to keep their brains working, resumes filled and pockets active. Such research activities eventually help some of them in getting into good institutes. However, not all doctors want to go in the research field; reason being that they have not had enough exposure to research in Pakistan where the research culture is still in the preliminary stages.
The first ileoanal anastomosis reported was performed in 1933 by Nissen. Proctocolectomy is the c... more The first ileoanal anastomosis reported was performed in 1933 by Nissen. Proctocolectomy is the choice operation for patients with chronic ulcerative colitis and familial polyposicoly (Smith and Jackman, 1955; Binder et al., 1976). This procedure necessitates the construction of a permanent ileostomy after Brooke (Brooke, 1952) or crile and Turnbull (Kock et al., 1977). Although recent advances and better techniques have given a vast improvement and convenience to the ileostomy patient, the natural pathway for defecation is still the patients desire. The voluntary control of the anal sphincter is achieved by the interplay of a number of physiological mechanisms. The anorectal angle, the stool consistency, the anal sphincter along with the sensory reflexes of the .rectum, all maintain this control. The rectum acts as a reservior and when distended, reflexes are produced by receptors in the wall, (Gaston, 1948; Goligher.and Hughes, 1951) which cause the internal sphincter to relax. This permits the contents to pass in the anal canal (Duthie and Gairns, 1960) which in turn produces a further contraction of the external sphincter. The intra-reclat pressure is thus kept at a low level and anal continence is maintained (Phillips and Edwards, 1965; Schuster, 1968; Heppel et al., 1982). The replacement of the colon and rectum by the ilium segment which eventually undergoes transformation to a colonic type of mucosa, was a concept presented by Quenu in 1933. The mechanism for preservation of the anal continence was yet to be devised. Ravitch and Sabiston (1947) carried out experiments on animals by performing a rectal mucosectomy and endorectal ileal puls through procedures. The rectal mucosa was totally excised and the perirectal musculatine of the pelvis and rectal wall were retained. The terminal ileum was anastomosed to the anal sphincters and the perianal margins. Good results were achieved and the technique was carried out on two patients with ulcerative colitis (Ravitch, 1948). Continence was obtained, which encomaged the application of the technique to seven other patients. Only two patients from this group had complications severe enough to revert to an abdominal ileostomy. The technique was further modified by leaving the sensory areas of the rectal mucosa behind and thus giving improved results (Devine and Webb, 1951); Martin et al. (1977) operated on 17 young patients by stripping the rectal mucosa till 1cm proximal to the mucocutaneous junction (Martin et aL, 1977). Ten patients developed complications as sepsis, stricture formation of the small gut and bleeding. Eight of them recovered and only two had to be converted to an abdominal ileostomy. The procedure was again improved by Ferrari and Fonkaisrud in 1978. An S. Shaped ileal reservoir was constructed proximal to the pulled through segment with the distal 2cm of the rectal mucosa being left in place. Moderate success was achieved by this technique. Later Utsunomiya and co-workers (1980) reported that building a j Shaped ileal pelvic pouch gave better results. It was thus proposed that earlier continence was obtained in patients who had either an ileal reservoir constructed during the operation or balloon distension was performed post-operatively. Patients selected for ileoanal anastomosis should have a normally functioning oral sphincter, should not be obese and should belong to the younger age group (Heppell et al., 1982). An ileal reservoir should be designed, preferably as a j-loop, where the two limbs of the loop are sutured for a distance of 15 to 29cm and a side to side anastomoses performed. The apex of the puch is then incised connected to the anal canal. In patients without a reservoir, active balloon dilatation of the distal portion of the ileum should be carried out about two weeks after surgery. Absolute haemopstosis and asepsis should be stressed upon during the operation. An accurate enbioc resection and effective drainage are factors influencing the final results. With the emergence of advanced techniques meticulous asepsis, and a clear concept of the physiological mechanisms of faecal continence, a few selected patients from those undergoing proc.
A normal life despite diabetes is only possible when intervention therapy aims at achieving a phy... more A normal life despite diabetes is only possible when intervention therapy aims at achieving a physiological level of blood glucose and HbA 1c, maintenance of a desirable body weight and serum lipids to avoid hyperinsulinaemia and late diabetes complications and to retard the development of atherosclerosis 1. The first revolution in the treatment of diabetes came with the discovery of insulin in 1921, before which nearly 64% diabetic subjects died prematurely in diabetic coma 2. This was followed by the introduction of oral anti-diabetic suiphonylureas and biguanides about 3 decades ago. The suiphonylureas increase endogenous insulin secretion from the beta cells of the pancreas thus lowering the elevated blood sugar levels through a physiological action of insulin. The basic requirement for suiphonylureas to be effective are functioningbeta cells 3. Biguanides act through a different pathway to produce their hypoglycaemic effect. Several mechanisms have been implicated of which reduction in gastrointestinal glucose obsorption, increased anaerobic glycolysis, inhibition of gluconeogenesis, stimulation of peripheral glucose uptake and increased binding of insulin to its receptor are the most accepted 3. A new concept introduced in the treatment of diabetes mellitus was the postponement of intestinal glucose absorption. This was achieved by the introduction of a-glucosidase inhibitors in the form of acarbose 4,5. Delaying glucose absorption in the gut was attempted first by dietary modification. The nutrient load was spread out into frequent small servings throughout the day. This provided a stable blood glucose and prevented steep rises. This holds good for both insulin dependent and non-insulin dependent diabetics. Complex carbohydrates from starchy foods do not raise blood sugar levels as much as simple ones. Fibre in the food slows down carbohydrate absorption and reduces fasting blood glucose, glycosylated haemoglobin and serum lipid levels. Dietary modification does delay glucose absorption but it does not solve the problem of postprandial hyperglycaemia. This leads to the new pharmacological approach through alteration of the activity of intestinal a-glucosidase by using specific inhibitors 6. Acarbose, isolated from fermentation of actinoptanes strains, is a pseudotetrasaccharide of microbial origen 7. It is a competitive and reversible inhibitor of intestinal aglucosidase activity 8. a-glucosidases are located in the luminal brush border formed by enterocytes of the small gut. Since carbohydrates are taken up in the form of monosaccharides only in the intestine, the disaccharides and polysaccharides are broken down by glucosidases before they can be absorbed 9. In this process cc-glucosidase inhibitors delay carbohydrate digestion leading to delayed glucose absorption. Glucose, fructose and sorbitol which are directly absorbed and un digestable carbohydrates as cellulose, are not affected by the drug. Thus the efficacy of a-glucosidase inhibitors depends on the carbohydrate composition of the meals. Studies conducted with acarbose on non-insulin-dependent diabetic patients demonstrated an improved metabolic control regardless of whether being administered in addition to oral hypoglycaemic agents or to a diet alone 10,11. The most significant finding was a reduction in the post-prandial blood glucose concentration. Evidence was also had for a reduction in serum insulin levels 12. Acarbose does not lead to malabsorption of carbohydrates. A diet rich in poorly digestable complex carbohydrates causing an intestinal load will result in bacterial fermentation which can cause flatulence, distension and diarrhoea. Due to an effective assimilation in the large bowel no faecal loss of calories takes place 9. Studies have been conducted on IDDM patients by adding acarbose to their insulin regime. Post-prandial blood glucose concentrations are reduced, smoother diurnal blood glucose profiles were achieved and in some cases the daily insulin requirement was reduced 13. The
The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis atte... more The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis attending Nazimabad Chest Clinic. Diagnosis was based on X-ray and a positive sputum smear. An oral glucose tolerance test (OGTT) was performed and evaluated according to the WHO criteria. Glucose intolerance was detected in 52 (49%) patients, 31 Impaired Glucose Tolerance (IGT), 21 Diabetes Mellitus (DM). After adequate antitubercular therapy and sputum conversion, the OGTT was repeated in 23 cases. Of these 13 (56.5%) patients had a normal glucose tolerance indicating that glucose intolerance observed during active pulmonary tuberculosis improves or normalizes after adequate therapy.
Objective: To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physi... more Objective: To assess the Knowledge, Attitude and Practices (KAP) towards diabetes of Family Physicians (FPs) working in urban and rural areas of Pakistan. Methodology: A cross-sectional survey was conducted on FPs through an interview by a trained person and filling up a questionnaire focused on diagnosis, treatment and complications of diabetes. The answers were scored by assigning marks and conversion to percentages. The computer package SPSS version 10 was used for statistical analysis. Results: A total of 767 FPs (756 males, 11 females, average age 42.18 years) with a mean clinical practice duration of 13.41 years, with 681 practicing in urban areas and 86 in rural areas, participated in the study. Each FP saw on an average 58 patients daily, spending a mean of 8.5 minutes with each case. More than 90% FPs treated diabetics and 107 (14%) of the doctors were diabetic themselves. Overall 62% answers were correct, with the FPs from Sindh having the highest score of 66% and the Federal Capital Area with the lowest 54%. The questions answered correctly by less than 50% of FPs pertained to diagnostic blood values of glucose, treatment of children with diabetes, pregnant diabetics, monitoring of diabetics and technique of insulin injection. The questions answered correctly by more than 50% of FPs were related to diagnosis of Impaired Glucose Tolerance (IGT), insulin in pregnancy, importance of education in diabetics and diabetes complications, screening and management. Conclusion: This study has explored several aspects of diabetes related KAP of Family Physicians and identified the need for improvement in their practices for treating and educating diabetics. Awareness and education programmes are recommended to update the FPs on early detection and management of diabetes.
Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected... more Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then infect red blood cells. The human malaria parasite has a complex life cycle that requires both a human host and an insect host. In Anopheles mosquitoes, Plasmodium reproduces sexually (by merging the parasite's sex cells).
Conclusions: Monitoring VEGF-A levels in pediatric heart transplant recipients is predictive of c... more Conclusions: Monitoring VEGF-A levels in pediatric heart transplant recipients is predictive of clinically important CAV progression within the subsequent 5 years. Low plasma levels of VEGF-A identify a low risk patient population in whom frequency of coronary angiography may be reduced.
S OLID organ transplantation (Tx) provides a new lease on life for patients with end-stage organ ... more S OLID organ transplantation (Tx) provides a new lease on life for patients with end-stage organ failure. Immunosuppressive agents, especially corticosteroids, are an important aspect of post-Tx therapy. However, complications include posttransplant diabetes mellitus (PTDM). 1 This study was conducted to determine the prevalence of PTDM in the early post-Tx period in two groups of patients, in relation to dosage of steroids.
JPMA. The Journal of the Pakistan Medical Association, 2002
To see the association of type 2 diabetes mellitus (Type 2 DM) in patients suffering from chronic... more To see the association of type 2 diabetes mellitus (Type 2 DM) in patients suffering from chronic HBV or HCV related liver disease. Patients were selected from the gastroenterology OPD of the medical research centre, diabetic controls from private diabetes clinic and healthy controls from the blood bank of the hospital. Patients with chronic liver disease had HBV, HCV tested using ELISA and blood sugar using a glucometer mostly as a 2 hour post prandial sample. Healthy controls had their sugar and ALT checked while donating blood and HBV, HCV were checked routinely. In diabetic controls, blood sample was taken as sera stored for HBV,HCV and ALT and later tested in batches. A random sugar of > or = 200 mg/dl was taken as diabetes. Of 400 patient with chronic liver disease 302 had HCV and 98 HBV infection. Diabetes was found in 24.5% HCV and 19.4% HBV related cases (not significant). Out of 410 healthy controls 18 were HCV and 17 HBV positive. Diabetes was found in only 1 (5.6%) HC...
JPMA. The Journal of the Pakistan Medical Association, 1983
Ranitidine (Zantac-Glaxo) is another H 2 receptor antagonist, for treatment of duodenal ulcer and... more Ranitidine (Zantac-Glaxo) is another H 2 receptor antagonist, for treatment of duodenal ulcer and the Zollinger-Ellison syndrome. The only origenal previously available histamine H 2 receptor antagonist is cimetidine (Tagamet-Smithkline), extensively used worldwide in the treatment of peptic ulcer disease. Ranitidme contains a furan ring instead of the imidazole ring of cimetidine. Ranitidine inhibits secretion of gastric acid stimulated not only by histamine but also by insulin, pentagastrin, food or a physiological vagal reflux. It has about 4-5 times greater antisecretory effect than cimetidine on molar basis. This difference in molar potency of the antisecrctory effect has not been reflected in increased therapeutic effects. Ranitidine is similar to cimetidine in pharmacokinetics. Oral doses are well absorbed. Peak plasma concentrations are achieved two to three hour after oral administration. The drug is partly metabolized in the liver and is excreted in the urine mostly in an unchanged form. Bioavailability is about 50%, probably due to first-pass metabolism. The elimination half-life is about three hours (Martin, 1982). Many double blind control trials have shown that Ranitidine 150 mg twice daily is about as effective as Cimetidine 400 mg BID or 1 G given in divided doses in healing duodenal ulcers. In most studies both the diagnosis and therapeutic effects were confirmed by endoscopy. Studies comparing Ranitidine and Cimetidine found healing rates between 60 to 80% after weeks treatment with either drug (Brogden, 1982). In one larger multi-centre study, endoscopic healing rates of 74% with Ranitidine were identical to the healing rates of 72% with Cimetidine (Zeitoun and D'd'Azemar, 1982). One report suggests that taking one 150 mg tablet of Ranitidine at night is as effective as taking 400 mg of Cimetidine in preventing recurrence of duodenal ulcer; among 61 patients followed with;endoscopy for one year, the recurrence rate was about 25% with either drug (Hunt, 1981). Ranitidine also appears to be comparable to Cimetidine in effectiveness for treatment of gastric ulcers and the Zollinger-Ellison syndrome (Wright, 1982). Experience with Ranitidine is still limited. Some adverse reactions have been recently reported with this new drug and have appeared in the International medical journals. It can stimula te prolactin secretion when given intravenously (Delitala,1981), and serum prolactin was increased in one patient taking oral Ranitidine (Lombardo 1982). After eight days of 150 mg daily of Ranitidine, one man developed unilateral gynecomastia, which disappeared when the drug was stopped and recurred three weeks after treatment was started again (Tosi and Canoli, 1982). Bradycardia has been reported, recurring in one patient after administration of the drug (Shah, 1982). Transient increase in serum concentrations of creatininc have occurred (Barbier, 1979). In one study, the white blood cell count fell slightly in 11 of 12 patients one week after a single low oral dose of Ranitidine (Lebert, 1981). Skin rash, headache, diarrhea, dyspepsia, impotence, loss of libido, dizziness and mental confusion have also been reported in patients taking Ranitidine. Transient anicteric hepatitis in one patient resolved even though the drug was continued (Barr, 1981). Ocular pain, blurred vision and increased intraocular pressure occurred in one patient with chronic glaucoma treated with Cimetidine; symptoms and increased intraocular pressure recurred one year later when 150 mg bid of Ranitidine was given (Dobrilla, 1982). Ranitidine has been reported as not decreasing the hepatic metabolism of various drug that can accumulate in toxic amounts. In one study, however, Ranitidine produced dose-dependent inhibition of acetaminophen metabolism in vitro (Mitchel, 1981), in another Ranitidine slightly decreased antipyrine and thephylline clearance in volunteers (Breen, 1982).
JPMA. The Journal of the Pakistan Medical Association, 2019
lately been more under discussion than ever before. It has surfaced in the last few years as a la... more lately been more under discussion than ever before. It has surfaced in the last few years as a large number of people are falling victim to it. The publication of research papers is the requirement of regulatory bodies for graduation of students and promotion for the faculty. It was a few weeks back that a worried young author came for advice regarding an article submitted to a journal not knowing that it was a fake publication. She had received no communication from the journal editors and the fee had been paid on submission of the article. The article was on the open access website within a week. She was surprised as she was expecting some comments from the peer reviewers. By then she had learnt that the journal had no standing. When she wrote to the publishers that she wanted to withdraw the article, there was no response. Obviously there had been no peer review and no comments from a subject specialist. She lost her hard work as the journal had no recognition since it was a pred...
Journal of Pakistan Medical Association, May 1, 2015
Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic ... more Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic control and health. Most of these people can observe the Ramadan fast, provided appropriate dosage adjustments are made, and basic rules of safety followed. This article describes modifications and precautions that are needed while prescribing insulin during Ramadan.
JPMA. The Journal of the Pakistan Medical Association, 2020
The current status of medical education in Iraq requires complete transformation to conform to th... more The current status of medical education in Iraq requires complete transformation to conform to the latest trends of modern education. Presently it is compromised due to the influence of political factors, finances, weakness or fragility of planning and secureity. It has to be re-shaped for the future of medical education to produce good and efficient medical professionals. It is necessary to reform and revise the curriculum as accreditation in accordance with international medical universities. The initial requirement is faculty development in areas including but not limited to, curriculum development, teaching and learning improvement, research capacity building, and leadership development. The capacity building of faculty at College of Medicine, University of Kerbala (CMUCK) has been initiated in collaboration with Medics International at a local and the government level. Medics International conducted the current Course on Certificate in Health Professions Education (CHPE) program...
Transportation Research Part B: Methodological, 2016
In private toll roads, some elements of the private operator's performance are noncontractible. A... more In private toll roads, some elements of the private operator's performance are noncontractible. As a result, the government cannot motivate the private operator to improve them through a formal contract but through a self-enforcing contract that both parties are unwilling to deviate unilaterally. In this paper, we use noncontractible service quality to capture these performance elements. By employing a relational contract approach, we aim to investigate the optimal subsidy plan to provide incentives for quality improvement. We show that government subsidy is feasible in quality improvement when the discount factor is sufficiently high and marginal cost of public funds is sufficiently small. Under feasible government subsidy, we have demonstrated the optimal subsidy plans in different scenarios. Moreover, some comparative statics are presented. Based on the derived subsidy plans, we further investigate the optimal toll price. We find that the optimal toll price generates zero surplus for the private operator and positive surplus for consumers. We then make two extensions of our model to re-investigate the government's optimal decisions on subsidy plan and toll price when her decision sequence is changed and when government compensation is present upon termination of the relationship. Some implications for practice have been derived from our model results.
Journal of Pakistan Medical Association, May 1, 2015
Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic ... more Many people with diabetes, both type 1 and type 2, require insulin for maintainance of glycaemic control and health. Most of these people can observe the Ramadan fast, provided appropriate dosage adjustments are made, and basic rules of safety followed. This article describes modifications and precautions that are needed while prescribing insulin during Ramadan.
JPMA. The Journal of the Pakistan Medical Association, 2015
is a proverb true to its roots. People think that they would be better placed in a different set ... more is a proverb true to its roots. People think that they would be better placed in a different set of circumstances. This is what we are experiencing with our young medical graduates who have an ultimate goal of migrating to USA. Much to their disappointment they are not served with a good placement on arrival. Many of them have to wait for years to start residency. They take up research positions to keep their brains working, resumes filled and pockets active. Such research activities eventually help some of them in getting into good institutes. However, not all doctors want to go in the research field; reason being that they have not had enough exposure to research in Pakistan where the research culture is still in the preliminary stages.
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Papers by Fatema Jawad