Osteoporosis and Osteopenia – A Rising Healthcare Problem

Shahid Kamal

With Asia housing 75% of humanity, and the proportion of seniors rapidly climbing from 5.3% in 2015 to 9.3% by 2025, Osteoporosis is rapidly becoming a growing medical ailment in this part of the world too [1].
In Pakistan, though clear data on occurrence of hip fractures (osteoporotic) annually is not established, large ultrasound studies suggest that there may be more than 9 million people (7 million women, 2 million men) afflicted with Osteoporosis. It is expected that these estimates may very well cross 12 million by the year 2050 – becoming a major health burden. Low per capita income and high hospital costs further derail the earning capacity.
Estimations indicate the population to cross 340 million by the year 2050, and of these 14.9% (50 million) will be over the age 60 years. A five year study from one hospital revealed a 2:1 female to male ratio of hip fracture cases, with 61 years being the average age of patients having osteoporotic fracture. This average age is lower than that reported in North America and Europe but matches data from India. Another study revealed 16% and 34% occurrence of osteoporosis and osteopenia respectively in females of age group 45 to 70 using ultrasound technique. Another study from KPK province estimated the numbers at 29 and 42% respectively. 75% of postmenopausal women from Peshawar seemed to be at risk of osteoporosis on a clinical risk score analysis [2-7].



Some Pertinent Solutions to the Challenges Faced by the Pakistani Healthcare Systems

Agha Muhammad Hammad Khan, Muneeb Uddin Karim, Neil Wallace, Fatima Shaukat and Muhammad Muaz Abbasi

Health systems worldwide face various challenges. Disparities are evident among different geographic locations. There are several hurdles in providing high-quality professional education, especially in low- and Lower-Middle-Income Countries (LMICs), including insufficient basic infrastructure and a shortage of professionally trained staff. This issue presents a particular risk in LMICs that are ill-equipped to deal with complex and expensive treatments [1, 2]. Although developing and enhancing educational programs to yield more healthcare professionals is constructive, these efforts need to be accompanied by educational structuring that will provide postgraduates with the necessary competencies [3]. It is not uncommon for the patients in LMICs with a potentially curable disease to receive sub-optimal treatment because of a lack of competencies and a caring attitude. This prompts some interesting challenges around the speciality training of postgraduates. In particular, what we are trying to achieve in modern oncology training programmes? Are current examination systems an effective test of knowledge, skills, and safety to practice? And, if so, are they sufficient to prepare for independent practice? Or should training programmes incorporate non-clinical skills related to issues? Interestingly, according to World Health Organization (W.H.O.), there are six elements or system building blocks of the health system that includes (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance [4]. We believe that these elements overlap with our proposal of inclusion of non-clinical leadership skills during their early years so that they are aware of the gaps and develop a mindset to improve the healthcare system by themselves.
In this paper, we propose these five concepts to be inducted into our postgraduate training that will pave the way to improve our healthcare system.

Received: April 08, 2022
Revised: September 03, 2022
Accepted: October 10, 2022



Association of Visceral Fat Index with Coronary Collateral Circulation in Patients with Coronary Artery Disease

Shazia Nazar, Erum Afaq, Shayan Zufishan, Nahida Baigam, Ghazala Masood Farrukh and Sumera Mustafa

Abstract: Background: Coronary collateral circulation (CCC) is a network of anastomosing channels, established by heart in response to ischemia of myocardium. Hypertension, diabetes mellitus, and BMI are well established risk factors for development of poor CCC. Good CCC minimizes symptoms of angina, reduce the size of infarcts and prevent adverse cardiac events. The current research study was designed to find out the association of visceral adiposity and development of CCC among patients with coronary artery disease.
Materials and Methods: The prospective study, conducted in Civil Hospital Karachi, comprised of 270 patients of coronary artery disease. According to the Rentrop Cohen categorization, patients were placed into two groups: the group with good collateral circulation having Rentrop grades i2-3 (n = 140) and the group with poor collateral circulation having Rentrop grades i0-1(n = 130). Rentrop score was determined by angiography. Segmental multi-frequency bioelectrical impedance analyzer was used to determine body fat mass and body muscle mass. Using Omron body fat and weight measurement systems, visceral fat index (VFI) was evaluated to determine the composition of visceral adipose tissue. SPSS was used for data analysis (Version 22). To assess the independent risk factor for poor CCC, logistic regression analysis was used. ROC curve was constructed to assess the efficacy of VFI in identifying CCC.
Results: Overall, good collateral circulations were observed in 51.9% (n=140) of CAD patients, whereas poor collateral circulations were ound in 48.1% (n=130) of patients. Poor CCC was significantly associated with hypertension (OR=3, 95%CI= 0.111-8.231, p = .001) and VFI (OR=2, 95%CI= 1.451-3.567, p =.001). ROC analysis revealed a VFI > 9 to be a potential predictor of poor CCC with AUC=0.9, sensitivity of 95.00% and specificity of 86%.
Conclusion: The current study concluded that greater VFI and concomitant hypertension considerably increase the likelihood of having poor CCC, therefore, visceral adiposity can be considered as a potential target for preventing poor collateral circulation in patients with established cardiac disease.

Received: April 19, 2023
Revised: June 15, 2023
Accepted: June 19, 2023



Assessment of Segmental Hepatic Fat Distribution using Magnetic Resonance Proton Density Fat Fraction MR-PDFF in Non-alcoholic Fatty Liver Disease (NAFLD)

Muhammad Salman Rafique, Ayesha Ayub, Ahmad Karim Malik, Tahir Malik, Sana Kundi and Abdullah Saeed

Abstract: Background: Non-Alcoholic Fatty Liver Disease (NAFLD) is a significant healthcare challenge. MR proton density fat fraction (MR-PDFF) is a quantitative imaging parameter that allows a precise estimation of hepatic steatosis. Determination of segmental and lobar fat distribution is also important since underestimation or overestimation may lead to hurdles in patient management and may also alter outcomes during liver donor assessment for living donor liver transplant.
Objective: To determine the heterogeneity of hepatic fat distribution across different liver segments and both lobes in patients with non-alcoholic fatty liver disease (NAFLD).
Materials and Methods: This cross-sectional descriptive study included 35 patients of NAFLD. MR-PDFF sequence was performed, two regions of interest (ROI) were drawn at the periphery of each hepatic segment and their mean was taken. We calculated mean values, ranges, and standard deviations for individual segments, both lobes and the entire liver. Pearson’s correlation was used to assess the relation between MR-PDFF and MR-PDFF variability. Paired sample t-test was utilized to compare the means of the right and the left lobe of the liver.
Results: The fat fraction in segment I was the lowest and in segment VII the highest. The right and left lobes showed a significant difference in fat fraction with values of 14% and 11.4% respectively (paired sample t-test, p<0.005). The left lobe showed a greater MR-PDFF variability than the right lobe (1.9 vs 1.6%).
Conclusion: In patients with NAFLD, segments VII and VIII show the greatest while segments I and IV show the least fat infiltration. Hepatic fat preferentially gets deposited more in the right lobe of the liver.

Received: April 10, 2023
Revised: May 24, 2023
Accepted: May 26, 2023



Benefits of Ferric Carboxymaltose Administration for Enhanced Hemoglobin Levels in Urban Population of Sindh: BOFERIN® Observational Study

Jahanara Ainuddin, Nasreen Majid, Azra Aslam, Raheel Sikander, Sarmad Iqbal and Syed Saad Hussain

Abstract: Background: Iron deficiency anemia is a major public health issue in developing countries, especially among women of reproductive age. Anemia is a major public health problem in women of reproductive age in rural Pakistan and a large proportion of women were found to have low levels of serum iron.
Materials and Methods: A multicenter observational cohort study was conducted at Karachi & Hyderabad from 8th February 2022 to 30th April 2022. Women with low hemoglobin level and age 18-45 years were included in this study. Patients were grouped according to 1-week assessment and 3-week assessment of hemoglobin concentration. A single dose of a generic substituent ferric carboxymaltose (Boferin®) was administered to the patients over 15 minutes infusion. Baseline hemoglobin levels were compared at 1 week and 3 weeks after administration of Ferric Carboxymaltose.
Results: A total of 104 patients were enrolled in this study. The mean hemoglobin levels at baseline were 9.22 ± 0.175 g/dl and 7.55 ± 0.329 g/ dl for 1-week and 3-week, respectively. The mean hemoglobin increases after 1 week and 3 week was reported as 1.4211± 0.169 g/dl (p< 0.001) and 2.321± 0.335 g/dl (p< 0.001) respectively. Only three patients presented with mild to moderate adverse effect which included abdominal discomfort and nausea.
Conclusion: This is a first in class study has shown statistically significant increase in hemoglobin at 1-week and 3-week interval with minimal side effects. It is concluded that Boferin® is efficacious in increasing hemoglobin levels in patients with iron deficiency anemia with its safety being documented in pregnant Pakistani population as well.

Received: November 21, 2022
Revised: April 19, 2023
Accepted: April 20, 2023



Barriers and Beliefs Related to Covid-19 Vaccine in a Rural Area of Peshawar, Pakistan

Abdul Adil Khan, Syed Imran Gillani, Qazi Haris Wadan and Syed Ibne Ali

Abstract: Background: After the corona virus outbreak, a new challenge has presented itself in the form of vaccine hesitancy, a decision which stems from personal beliefs and perceptions, which may lead to the prevalence of a disease that can otherwise easily dealt with.
Objectives: This study aimed to determine the barriers and beliefs related to COVID-19 vaccine in a rural area of Peshawar, Pakistan.
Materials and Methods: An analytical cross-sectional study was conducted from May 2021 to October 2021 on a population from rural areas of Peshawar with a non-probability convenience sampling technique. An interview based self-administered questionnaire was used with questions regarding beliefs and about the COVID-19 vaccine as well as their vaccination status. An SPSS software was used to analyze the data for descriptive as well as inferential statistics.
Results: A total of 526 people from the rural area participated in our study with 73% males (n = 384) and 27% females (n = 142). Only 23.6% got vaccinated voluntarily, 8% agreed that there was enough information available regarding the vaccine to trust, around 17.5% agreed the vaccine does not cause adverse reactions, only 15.6% believed that the vaccine had no unknown side effects, 22.1% trusted the vaccine to be effective in combating the coronavirus while 54.4% believed it to be a conspiracy.
Conclusion: Vaccine hesitancy was quite profound which was caused by the amalgamation of many negative beliefs based on claims that had no sound basis. A great confusion surrounds the COVID-19 vaccine for the people of the rural area who are concerned about various aspects of the vaccine.

Received: April 03, 2023
Revised: June 14, 2023
Accepted: June 19, 2023



Experience of Physical Examination as a Primary Tool for Surgical Access Planning in Hemodialysis Patients

Waqar Ahmed Memon, Javed Altaf Jat, Pooran Mal, Adeel Hyder Arain, Taimoor Ahmed Jatoi, Ahsan Ali Arain and Ansar Ahmed

Abstract: Background: Understanding the importance of pre-operative assessment is something nephrologists are probing for years to avoid any post-operative complication and AVF failure.
Objective: To assess the physical examination as primary tool as compared to Ultrasound Doppler in assessment of AVF planning in hemodialysis patients.
Materials and Methods: This was a Retrospective, Cross-sectional study. Secondary data was collected from the Urology Department of Liquate University of Medical and health sciences, Jamshoro starting from October 2021 to October 2022. For physical examination, both the arterial and venous circulation were evaluated. Arterial patency, pulse amplitude and Allen’s test were recorded. After collection of data, statistical Package for Social Science (SPSS) version 17. 0 statistical software was used for analysis.
Results: A total of 105 participants with mean age of 42.9 ± 13.9 years, 78 (74.3%) males and 27 (25.7%) females were included. The physical examination findings indicated facial swelling as the most frequently reported sign in with 59 (56.2%) of patients, followed by generalized body edema reported in 22 (21%) of participants. The estimated analysis of Allen’s test indicated good results with a mean of 12.4 ± 2.8 seconds in all patients, indicating good blood flow of the ulnar artery. The mean duration of hemodialysis was 55.2 ± 23.4 days before AVF, while central venous line duration was 57.2 ± 20.5 days. After 6 days fistula maturation was assessed, while mean fistula maturation duration was 44 ± 7.1 days.
Conclusion: To monitor functioning, the Physical Examination of vascular access is convenient, straightforward, and cost-effective. Physical examination (PE) has been validated with diagnostic techniques for detecting stenosis.

Received: April 04, 2023
Revised: June 14, 2023
Accepted: June 15, 2023



Validation of MRI Quantification of Liver Fat, Keeping CT Liver Attenuation Index (LAI) as Gold Standard

Faryal Ijaz, Samina Khan, Muhammad Salman Rafique, Sana Kundi, Tahir Malik and Ahmad Karim Malik

Abstract: Background: Non – Alcoholic Fatty Liver Disease (NAFLD) is emerging as a considerable health problem in patients visiting gastroenterology clinics. It is of crucial importance to evaluate the extent of hepatic steatosis in potential candidates for living donor liver transplantation (LDLT) to ensure donor safety as well as optimum graft regeneration.
Objective: To validate the MRI quantification of liver fat keeping CT liver attenuation index as gold standard.
Materials and Methods: This cross-sectional study was carried out in the department of Diagnostic Radiology, Pakistan Kidney and Liver Institute and Research Centre from 10th October, 2022 to 10th December, 2022. We determined the sample size using WHO sample size calculator. The MR fat fraction sequence was acquired as a part of the obligatory MRCP in 70 potential liver donors who undertook CT abdomen. Liver Attenuation Index (LAI) and MR fat fraction were determined separately by two radiologists who were blinded to each other. LAI was calculated as: Mean liver attenuation – mean splenic attenuation. MRI fat fraction from seven areas of liver were taken and their mean calculated to determine the percentage of liver fat. SPSS version 20 was employed for statistical analysis and Pearson’s Correlation was applied.
Results: Among the 70 donors 42 were males and 28 were females (M: F= 1.5: 1). The hepatic fat fraction values on MR were correlated with the liver attenuation index on CT using a two – tailed Pearson correlation test. The results showed a very strong negative correlation between the two; the lower the LAI, the higher the MR fat fraction (Pearson correlation coefficient r = -0.932, p<0.05).
Conclusion: Strong correlation was found between MRI estimation of liver fat and CT LAI fat estimation. MRI is safer than CT as it does not involve ionizing radiation, is quicker to perform, and hence can be recommended as future method of choice.

Received: January 01, 2023
Revised: June 05, 2023
Accepted: June 07, 2023



Pantothenate Kinase Deficiency Related Neurodegeneration (PKAN) – An Ultra Rare Inherited Metabolic Disorder

Mahnoor Saeed, Muhammad Saeed, Ali Maqbool, Badriah G. Alasmari and Ali Mujtaba Tahir

Abstract: Pantothenate Kinase-related Neurodegeneration (PKAN) is an Autosomal Recessive (AR) inherited disease identified by focal iron accumulation in the basal ganglia. Formerly recognized as Hallervorden-Spatz disease. PKAN is now considered to be one of several diseases that clinically presents with Neurodegeneration due to deposition of iron in brain (NBIA). Here, we describe an eleven-year-old boy identified as typical PKAN.

Received: April 04, 2023
Revised: May 18, 2023
Accepted: May 25, 2023



Giant Lipoma of Unusual Regions: A Case Series of Two Unfortunate Adults

Badaruddin Sahito, Javeria Qamar, Sajjad Ahmed and Muhammad Waqas Khan

Abstract: Lipomas are prevalent, benign, asymptomatic mesenchymal tumors that can develop in various areas where adipose tissue is present. However, when lipomas reach sizes larger than 10 cm in width or exceed 1 kilogram in weight, they are classified as giant lipomas [1-3]. These oversized lipomas can lead to functional restrictions, aesthetic concerns, and compression-related injuries, all of which can negatively impact an individual’s quality of life. They are usually surgically removed to avoid injury to major neurovascular structures; however, they have a predisposition for recurrence and the risk of malignancy following surgery. This case series discusses the clinical findings and surgical treatment of two patients who had enormous, deformable, fatty tumors of buttocks and thigh, respectively.

Received: March 04, 2023
Revised: June 08, 2023
Accepted: June 09, 2023




NJHS Front Page v8.n2
2023 VOL 8 , Issue 2