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Volume 1, Issue 2

July - September, 2013

Aims and Scope
El Mednifico Journal is an open access, quarterly, peer-reviewed journal from Pakistan that aims to publish scientifically sound research across all fields of biology and medicine. It is the first journal from Pakistan that publishes researches as soon as they are ready, without waiting to be assigned to an issue. The journal serves as a healthy platform for students and undergraduates, whose articles are considered on the basis of content and not on the basis of topic or scope. However, strict quality measures ensure a high standard. The journal has certain unique characteristics:  EMJ is one of the first journals from Pakistan that publishes articles in provisional versions as soon as they are ready, without waiting for an issue to come out. These articles are then proofread, copyedited and arranged into four issues per volume and one volume per year EMJ is one of the few journals where students and undergraduates form an integral part of the editorial team EMJ is one of the few journals that provides incentives to students and undergraduates

 

The rationale behind starting a journal offering incentives to students is three fold:    To inculcate a sense of research in biomedical students by promoting healthy writing practices To provide a platform where students can publish their research (after thorough peer review) without the fear of getting rejected on the basis of topic or focus of the article To ensure global outreach for articles published in the journal

EMJ is published once every 3 months by Mednifico Publishers. Editorial correspondence should be addressed to: The Editor-in-Chief, El Mednifico Journal, C2 Block R, North Nazimabad, Karachi, Sindh - 74700 - Pakistan. Tel: (92-334-2090696); Email: editorial@mednifico.com; Website: http://mednifico.com Articles should be sent to: Submissions EMJ, C2 Block R, North Nazimabad, Karachi, Sindh - 74700 - Pakistan. Email: submit@mednifico.com Want to partner with EMJ? Send your proposal to: partnership@mednifico.com We’re hiring! Send your CVs to: apply@mednifico.com i

Editorial Board
Senior Editor-in-Chief
Prof. Nazeer Khan

Executive Editors
Syed Salman Ahmed, Sajid Ali Dr. Mansoor Husain, Dr. Muzaffar H Qazilbash, Dr. Tasneem Z Naqvi, Prof. Haruhiro Inoue, Dr. Athanassios Kyrgidis, Dr. Asim A Shah, Dr. Kothandam Sivakumar, Dr. Samina Abidi, Dr. Rashid Mazhar,

Editor-in-Chief
Asfandyar Sheikh

Managing Editor
Syed Arsalan Ali

Senior Editors
Dr. Gautam Sikka, Dr. Mosaddiq Iqbal, Prof. Javed Akram, Prof. Abdul Bari Khan, Prof. Ashraf Ganatra, Dr. Raza Ur Rehman, Dr. Waris Qidwai, Dr. Muhammad Ishaq Ghori, Dr. Akber Agha, Dr. Adnan Mustafa Zubairi, Dr. Saqib Ansari, Dr. Mohsina Ibrahim, Dr. Qamaruddin Nizami, Dr. Samra Bashir, Dr. Nabeel Manzar, Muhammad Ashar Malik

Section Editors
Ali Sajjad, Hafiz Muhammad Aslam, Syed Askari Hasan, Muhammad Uzair Rauf, Syed Mumtaz Ali Naqvi, Manish Khazane, Smitha N Gowda, Supriya Kumar, Zeba Unnisa, Suhasis Mondal,

Assistant Editors Editors
Dr. Hussain Muhammad Abdullah, Asfandyar Khan Niazi, Muhammad Danish Saleem, Smith Giri, Iqra Ansari Gulrayz Ahmed, Raza Mahmood Hussain, Uzair Ahmed Siddiqui, Maheen Anwer, Anum Saleem, Hira Hussain Khan, Imran Jawaid, Hina Azhar Usmani, Shayan Ali, Shoaib Bhatti, Shanawer Khan, Hira Burhan, Quratulain Ghori

Statistics Editors
Mehwish Hussain, Syed Ali Adnan

Layout Editor
Shahzad Anwar

Copyeditors
Adnan Salim, Bushra Iqbal, Maria Rahim

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Table of Contents
FrontPage Editorial Board Call for Papers Table of Contents i ii iii iv

Editorial
Deteriorating situation of polio eradication in Pakistan
Hira Burhan, Syed Askari Hasan

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Original Articles
Frequency, indications and complications of midline laparotomy at a tertiary care hospital in Karachi
Zahid Memon, Irma Anis, Batool Fatima, Mustafa Abbas, Rabyyan Junaid, Sidra Mahmood

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Factors influencing the choice of a medical specialty among medical students
Areeba Saif, Syed Askari Hasan, Tahrim Farrukh, Najla Khan, Hira Batool, Tooba Baqai

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Short Report
Opinions of medical students regarding prolongation of mechanical ventilation versus unassisted death
Zehra Aqeel Nizami, Neha Aijaz, Khushbakht Nargiza, Ghazal Arif Siddiqui, Ayesha Rida, Omama Shakeel, Iqra Irfan, Anita Ghazal, Maryam Kaukab, Fatima Iqtidar, Javeria Siddiqui, Asna Sultana, Nida Shafi, Masood Abro, Safdar Bhutto

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Review
Overview of the role of atrial natriuretic peptide in cardiac pathophysiology
Syed Waqar Ali, Ruba Ali Zahid, Maheen Anwer, Anum Saleem, Syed Arsalan Ali

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Opinions and Debates
Health insurance: Can it work in Pakistan?
Huda Naim, Hassan Bin Ajmal, Gulrayz Ahmed, Muhammad Danish Saleem

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iv

Essays
The pathophysiological profile of interleukin-6 and anti-interleukin-6 antibody
Rafaqat Bota, Mushtaq Ahmed

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Childhood Pneumonia - A never ending, developing world concern
Shaikh Hamiz ul Fawwad, Gulrayz Ahmed, Syed Arsalan Ali, Anum Saleem

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Letters to Editor
A case of typical hemolytic uremic syndrome requiring three months of hemodialysis
Danish Waqar

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Pelizaeus-Merzbacher disease - A rare dreadful disease
Siddharth Mahajan, Parama Sahoo

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Appendices
Instructions to Authors Best of Blogemia vi ix

v

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Deteriorating situation of polio eradication in Pakistan

Open Access
Deteriorating situation of polio eradication in Pakistan
Hira Burhan1, Syed Askari Hasan1

Editorial

Editorial1
Wild Polioviruses (WPV) have continued to be endemic in Nigeria, Pakistan and Afghanistan [1]. Out of these, Pakistan remains a major epidemiological reservoir [2]. Pakistan’s Polio Eradication Initiative, started in 1994 and conducted National Immunization Days annually, giving Oral Polio Vaccine to children under 5 years of age [3]. Decreased vaccination coverage led to the launch of a National Emergency Action Plan in 2011, targeting 33 districts with a high incidence of poliomyelitis in Khyber Pakhtunkhwa (KP), Federally Administered Tribal Areas (FATA), Baluchistan, and Sindh. This plan was further augmented with tighter oversight and vigorous monitoring [3]. However, according to the data presented on 11th December 2012 by the Global Polio Eradication Initiative, the total number of WPV cases in Pakistan for the year 2012 remains 56, reaching a staggering 315 in the past three years! Poor performance of Expanded Program of Immunization (EPI) and lack of information about immunization contribute to this large number [4]. Failure to immunize children at an early age and vaccinate them regularly is another cause [1, 2, 4]. Religious taboos along with armed conflicts and security concerns in the tribal areas are the major hindrances limiting access to children during vaccination campaigns [3, 5]. Abduction and physical harassment of the vaccination personnel has increased over the past years. Recently, nine Pakistanis workers, including six women, were killed in KP province and the city of Karachi during the National Immunization Days from 17th to 18th December. The Human Rights Commission of Pakistan (HRCP) condemned these killings and demanded arrest of the perpetrators. The WHO has called off its campaigns as a result of these killings.

Once the workforce refuses to work, polio eradication will become more difficult than ever before. In order to keep the hope of eradication alive, the government must ensure security to health workers and reorganize the available Local Health Workers in order to raise community access and compliance to the service significantly [3]. The government should seek assistance from religious scholars for eliminating false conceptions that would help counsel the mindset of the masses. Pakistan’s continued status as an endemic reservoir may pose a significant threat to the nation’s economy, as travel restrictions may be imposed upon travelers due to a fear of “imported cases”.
Competing interests: The authors are editors at El Mednifico Journal. Received: 26 March 2013 Accepted: 23 April 2012 Published: 24 April 2013

References
1. Nathanson N, Kew OM: From emergence to eradication: the epidemiology of poliomyelitis deconstructed. American journal of epidemiology 2010, 172(11):1213-1229. 2. Obregón R, Chitnis K, Morry C, Feek W, Bates J, Galway M, Ogden E: Achieving polio eradication: a review of health communication evidence and lessons learned in India and Pakistan. Bulletin of the World Health Organization 2009, 87(8):624-630. 3. O'Reilly KM, Durry E, ul Islam O, Quddus A, Abid N, Mir TP, Tangermann RH, Aylward RB, Grassly NC: The effect of mass immunisation campaigns and new oral poliovirus vaccines on the incidence of poliomyelitis in Pakistan and Afghanistan, 2001-11: a retrospective analysis. Lancet 2012, 380(9840):491498. 4. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar MB, Sumrin A: Resistance of polio to its eradication in Pakistan. Virol J 2011, 8:457. 5. Warraich HJ: Religious opposition to polio vaccination. Emerging infectious diseases 2009, 15(6):978.

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Dow Medical College, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Syed Askari Hasan Email: askari_hasan2004@hotmail.com
Vol 1, No 2

Memon Z, Anis I, Fatima B et al.

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Open Access
Zahid Memon1, Irma Anis2, Batool Fatima2, Mustafa Abbas2, Rabyyan Junaid2, Sidra Mahmood2

Original Article

Frequency, indications and complications of midline laparotomy at a tertiary care hospital in Karachi
Abstract
Background: Laparotomy is a rapid and cost-effective means of managing acute abdominal conditions and trauma. However, it can result in complications that cause considerable morbidity and mortality. The aim of our study was to determine the frequency, indications and common post-operative complications arising after midline laparotomies at a tertiary care hospital. Methods: This was a cross-sectional study carried out at Civil Hospital Karachi (CHK). All patients undergoing midline laparotomy at CHK between June, 2009 and November, 2010 were included. Their bio-data, mode of admission, time of surgery, indication for surgery and surgical findings were noted post-operatively. Daily follow up of all patients was done during their post-op hospital stay and appearance of early complications, if any, were noted. All surgical wards were visited regularly for 18 months (up to May 2011) to check for readmittance of those patients due to any complication arising from their parent laparotomy. Results: A total of 384 patients underwent laparotomy during our study period. 262 (68.2%) were males and 122 (31.8%) were females. 121 males and 78 females developed complications. 340 (88.5%) laparotomies were conducted in emergency and only 44 (11.5%) were elective. 179 (62.6%) emergency cases developed 228 complications and 20 (45.5%) elective cases developed 28 complications. Most common indication for laparotomy was small intestinal perforation seen in 19.4% of emergency and 27.3% of elective cases. Wound infection, the most common complication, was responsible for 21.5% and 27.27% of the total complications of emergency and elective laparotomies respectively. Conclusion: Most of the laparotomies conducted are emergency in nature. Complication rate is very high in both emergency and elective cases. (El Med J 1:2; 2013) Keywords: Laparotomy, Surgery, Complications, Civil Hospital Karachi, Pakistan

Introduction
The word laparotomy is derived from the Greek word laparos meaning ‘soft or loose’. However, the word laparotomy is broadly used with any surgery requiring the opening of the abdominal wall and exploration of the underlying structures. Elective laparotomy can be defined as a laparotomy performed at a time to suit both the patient and surgeon, implying that there is ample time for preoperative assessment and preparation of the patient. On the other hand, an emergency laparotomy is a lifesaving procedure and is undertaken mostly in acute cases, without much preparation of the patient. Major indications for laparotomy can be divided into trauma and non-trauma categories. Blunt trauma accounts for 80-90% of all civilian trauma cases, however, laparotomy is required in only 30–40 % of these patients [1]. Penetrating trauma (gunshot, stab wounds) to the abdomen is associated with a higher number of intraabdominal injuries and under such circumstances emergency exploration is considered mandatory by many surgeons [2]. In the non-trauma setting, the most common indication requiring abdominal surgical intervention is acute abdomen. Acute appendicitis followed by peritonitis account for the majority of cases seen with acute abdomen in both male and female patients [3]. Post-operative complications can be defined as any outcome perceived negatively by the doctor or patient. They may occur intraoperatively, in the immediate post-operative period or even after considerable time has elapsed [4]. These post-op complications not only create great distress in terms of prolonged hospital stay and decreased social activity, but also create a great financial strain on
1 2

the patient and his family not only in terms of hospital bills but also due to decreased economic turnover. As expected, emergency laparotomies are associated with greater morbidity and mortality [5]. Other major contributing factors towards the development of complications are age and gender. Patients aged 65 and over undergoing emergency intervention have a higher mortality. Women were also found to have a higher risk than men [6]. Laparotomy being one of the most frequently performed procedures in any surgical setup is associated with a higher number of complications. Therefore, special attention must be paid to avoid and manage these post-operative complications as they are associated with considerable morbidity and mortality. The objectives of this study were to document the frequency and most common indications of midline laparotomies, to differentiate between the traumatic and non-traumatic causes and to determine the frequency of different post-op complications arising as a result of laparotomy.

Methods
This descriptive cross-sectional study was carried out in all surgical units of Civil Hospital Karachi. The primary cases considered were midline laparotomies taking place between June 2009 to November 2010. The data was collected from the participants by convenient sampling in the form of an oral interview after explaining the purpose of the study and taking a formal consent. The cases were divided on the basis of mode of admission into elective and

Civil Hospital Karachi, Pakistan Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Irma Anis Email: dr.irmaanis@gmail.com
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28 emergency cases. In all cases pre anesthetic assessment was done and informed consent was taken regarding the possible complications and outcomes of the surgery. Pre-operative baseline investigations such as complete blood picture, urea, creatinine, electrolytes, random blood sugar, ESR and x-ray chest were also performed. A prophylactic dose of antibiotic was given in case of elective laparotomies which were continued post-operatively as well. In emergency cases, a drip of broad spectrum antibiotic was maintained. Blood was sent for cross matching as well in both cases and at least two pints were made available especially in emergency cases. All the laparotomies were done under general anesthesia. A vertical midline incision following linea alba was given in all cases. After completion, the incision was closed using proline no. 1 suture. Details such as bio data, mode of admission, time of surgery, indications for the surgery, surgeon and anesthetists’ name, surgery notes and findings were noted post-operatively. The appearances of early complications like post-op nausea/vomiting, fever, wound infection and pulmonary complications were checked daily. The patients and their attendants were asked direct questions as well as their progress was checked by consulting from their files. The surgical site was also inspected regularly for the appearance of signs of infection during their stay. We included all patients as part of our study who underwent their parent laparotomy in CHK, whether elective or emergency, between June 2009 to November 2010. Among these patients, those who developed a complication either during their post-op stay, or were re admitted in CHK within 18 months of their parent laparotomy were re-interviewed to note the complication and its time of appearance. A thorough follow up in all the surgical wards was done for a period of 18 months to check for re- admittance of patients. Collected data was entered and analyzed on SPSSv18. Categorical data was presented in the form of simple frequencies and percentages. Participants were divided on the basis of their mode of surgery (elective or emergency) into two groups for most of the statistical analyses. Associations between variables were found by Chi-square tests. P value <0.05 was considered significant. Data was represented in the form of tables and bar charts where needed.

Frequency, indications and complications of midline laparotomy

(11.5%) were elective. 179 (62.6%) out of 340 emergency laparotomies presented with a total of 228 complications later on. However, 20 out of 44 elective cases (45.5%) were also found to have a total of 22 complications. Chi square test, applied to find out any statistically significant difference in the number of complications arising after elective and emergency laparotomies, revealed a statistically insignificant difference (p value = 0.230). Wound infection, the most common complication reported, was responsible for 21.5 % and 27.3% of the total complications of emergency and elective laparotomies, respectively. There were a total of 55 patients who developed wound infection. Majority of them (27.3%) had small intestinal perforation. Incisional hernia was the second most frequently encountered complication in both elective (18.2%) and emergency laparotomies (18.4%). Wound dehiscence/ burst abdomen complicated 28 cases of emergency laparotomy (12.28%) and only 2 cases of elective laparotomy (9.09%). Similarly, fecal fistula was also predominantly reported in laparotomies that were conducted in emergency, making up about 11.4% of total complications of emergency laparotomies. Figures 1 and 2 provide a graphical representation of the data.
7 Number of Patients Number of Patients 6 5 4 3 2 1 0

Figure 1: Complications of Elective Laparotomy
60 50 40 30 20 10 0

Results
A total of 384 patients undergoing laparotomy through vertical incision at surgical units of CHK were studied. Among them, 262 (68.2%) were males and 122 (31.8%) were females. Out of 262 males, 141 had no complications, 105 males presented with 1 post-op complication and 16 presented with more than 1 complications of laparotomy. Likewise, 44 females presented with no complication, 70 had 1 complication and only 8 ended up with more than one complication within 18 months of their laparotomy. Of the total, 199 patients suffered from at least one complication of laparotomy. Majority of the patients (34.4%) included in our study were in the age group of 10-25 years. There were a total of 32 elderly patients (age > 60). Complication rate was found to be highest in the age group of 26-40 with 72 out of 120 patients (60%) presenting with one or more complication. Out of 384 laparotomies, 340 (88.5%) were emergency and only 44
Vol 1, No 2

Figure 2: Complications of Emergency Laparotomy

Memon Z, Anis I, Fatima B et al.

29 abdomen as the most common reason for emergency laparotomy [7]. Perforation of any segment of gut is an acute condition in which patient presents in emergency with severe abdominal pain, nausea and vomiting. If the patient is clinically unstable and toxic, surgical intervention becomes mandatory in the form of exploratory laparotomy. A major chunk of the patient also presented to the emergency with gunshot wounds. Although historically encountered less than stab wounds, gunshot wounds dominated our study as being the 3rd most common indication for emergency laparotomy. Gunshot wounds carry a higher mortality due to extensive injury by the missile tract. In a study carried out by Nicolas and Rix, 250 patients who underwent laparotomy due to penetrating abdominal trauma were reviewed retrospectively and the survival rate was found to be 86.8% [8]. As to the effect of age, the rate of post-op complication in the present study was highest in the age group 26-40. This is not in accordance to the data seen in previous studies which showed that elderly patients undergoing laparotomy have a high risk of dying [6]. This relative imbalance, in our study, can be explained by the fact that our sample had relatively less number of elderly patients as compared to the patients in other age groups. Wound dehiscence/ burst abdomen is a very serious post-op complication that is a source of worry for every abdominal surgeon. It is associated with high morbidity and mortality. Mortality rate was found to be 10% in a study by Girish Parmar [9]. The rate of burst abdomen in our study was calculated to be 7.81% which is very high as compared to various international studies. The incidence rate by Girish Parmar was 5.6%, 8.13% by Afzal and 5.9% by Waqar [9-11]. Burst abdomen was seen more commonly in emergency laparotomies, a finding consistent with that reported by Afzal S and S H waqar [10, 11]. In our study, majority of the patients with burst abdomen presented after 11 days of surgery as compared to 7 days reported by Girish Parmar [9]. A study carried by Bucknall et al showed that mass closure technique reduced the development of burst abdomen by almost 2% [12]. Incisional hernia is associated with significant post-operative morbidity. The rate of incisional hernia was found to be 12.0% in our study as compared to 4.3% reported by Hoer [13]. A 10 year prospective study by Mudge reported an incidence of 11% and 35% of these appeared after 5 years of surgery [14]. Considering the fact that in our study patients presenting with a complication within 1.5 years of surgery were included, incidence rate of 12.0% is definitely a big concern. Majority of patients in this study developed incisional hernia on an average of 199 days (six and a half month) after surgery, a finding consistent with Hoer study revealing highest incidence (31.5%) in the first 6 months of surgery [13]. Simple adjustments in suture techniques can reduce the incidence of incisional hernia. Conze has proposed the implantation of mesh prosthesis to decrease the recurrence of incisional hernia [15]. Surgical site infection / wound infection is a nuisance to the patient in terms of pain and suffering, and also poses significant burden to the healthcare system because of prolonged hospital stay. A study on the incidence and economic burden of surgical site infections in Europe reported that the mean length of extended stay attributable
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Gut perforation was the most common indication for which majority of the emergency as well as elective laparotomies was performed. 19.4% of emergency and 27.3% of elective laparotomies had small intestinal perforation as their sole indication making it the leading indication for which most of the laparotomies were conducted in that time period. Perforated appendix (10.6%), perforated peptic ulcer (14.1%), perforated gall bladder (4.7%) and large intestinal perforation (3.5%) were some other gut perforations seen in cases of emergency laparotomies only. Other common non-traumatic indications for laparotomy included adhesions (emergency n=28, elective n=0), intestinal TB (emergency n=22, elective n=4), ruptured liver abscess (emergency n=12, elective n=0) and sub-acute intestinal obstruction (emergency n=8, elective n=4). Traumatic indications of laparotomy were present in only emergency laparotomies. Amongst the traumatic causes, gunshot wound was the indication in 10% of emergency laparotomies. Blunt trauma (8.8%) was seen next in frequency followed by road traffic accident (3.5%) and stab wound (1.2%) respectively. Table 1 gives a tabular representation of the data. Table 1: Indications of Laparotomy Indications Traumatic Gunshot Blunt Trauma Road Traffic Accident Stab Wound Small Intestinal Perforation Perforated Appendix Adhesions Intestinal Tuberculosis Perforated Gall Bladder Perforated Peptic Ulcer Primary Peritonitis Large Intestinal Perforation Ruptured Liver Abscess Sub-acute Intestinal Obstruction Volvulus (Sigmoid/Cecal) Mesenteric Cyst Retroperitoneal Mass Strictures Carcinoma of Gut Internal Hernia Sigmoid Mass Other Emergency (n) 34 30 12 4 66 36 28 22 16 14 14 12 12 8 6 6 4 4 2 2 0 8 Elective (n) 0 0 0 0 12 0 0 4 0 0 0 0 0 4 0 0 4 2 6 0 4 8

Nontraumatic

Discussion
Our findings show that majority of the laparotomies conducted in one of the leading tertiary care hospital of Karachi are emergency in nature, with gut perforation being the most common indication for both emergency and elective laparotomies. Murtaza et al also documented acute perforated appendicitis leading to acute

30 to it was 9.8 days, at an average cost per day of €325 [16]. The incidence of surgical site infection in this study was 14.32% comparable with 15.6% reported by Ussiri [17]. The infection rate is highest in dirty and contaminated wounds i.e. 7.1% and 6.4% respectively provided by the U.S. National Nosocomial Infection Surveillance [18]. The effect of wound closure seen on healing as studied by Scott et al showed that delayed primary and secondary wound closure in contaminated incisions significantly reduces the risk of wound infections and incisional hernias [19]. Studies have shown that wound infections can be influenced by factors such as surgical techniques, skin preparations, antibiotic prophylaxis and the timing and method of wound closure [18, 19]. Fecal fistula is an abnormal tract between the gastrointestinal tract and the skin. It is a very preventable state as 75% to 85% of enterocutaneous fistulas appear as a post-op complication [20]. It is an emerging complication seen in laparotomies, with mortality rate between 7% to 20% in non-trauma patients and 14% in trauma patients as reported by Fischer [21]. Our study showed an overall incidence of 7.2% in the total of 384 laparotomies studied. Majority of the patients who developed fecal fistulas as a post-op complication were initially operated for large intestinal perforation and blunt trauma. Prolonged fecal fistulas can lead to severe fluid and electrolyte imbalance, malnutrition and sepsis [22]. 40% to 70% fecal fistula close spontaneously within four to six weeks. However, if they fail to close despite adequate metabolic and nutritional status, surgical treatment becomes mandatory [23]. Fecal fistulas have a significant impact on hospital and patient resources by increasing the length of ICU and ward stay. Therefore, concrete steps should be taken to prevent this costly and troublesome complication. Recent trend in management of all forms of surgical problems are towards minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomies. The Eastern Association for the Surgery of Trauma reported a 23-53% and 5.3-27% rate of unnecessary laparotomies for patients with stab wounds and gunshot wounds, respectively [24]. Complication rates from laparotomy must, however, be weighed against the mortality and morbidity of a missed injury. The surgeon deciding whether or not a laparotomy is indicated must know the risks and benefits associated with either course of action.

Frequency, indications and complications of midline laparotomy

Acknowledgment: Our special thanks to Prof. Naheed Sultana, Dean of Surgery, CHK and DUHS. We are also grateful to the head of departments of all surgery wards of CHK. Competing interests: The authors declare that no competing interests exist. Received: 15 May 2013 Accepted: 10 July 2013 Published Online: 11 July 2013

References
1. Malhotra AK, Ivatury RR, Latifi R: Blunt abdominal trauma: evaluation and indications for laparotomy. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society 2002, 91(1):52-57. 2. McConnell DB, Trunkey DD: Nonoperative management of abdominal trauma. The Surgical clinics of North America 1990, 70(3):677-688. 3. Laal M, Mardanloo A: Acute abdomen; pre and post-laparotomy diagnosis. Int J Coll Res Intern Med Public Health 2009, 1:157-165. 4. Dermatological surgical complications. [http://www.emedicine.com/ derm/topic829.html] 5. Edwards AE, Seymour DG, McCarthy JM, Crumplin MK: A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia 1996, 51(1):310. 6. Cook TM, Day CJ: Hospital mortality after urgent and emergency laparotomy in patients aged 65 yr and over. Risk and prediction of risk using multiple logistic regression analysis. British journal of anaesthesia 1998, 80(6):776-781. 7. Murtaza B, Saeed S, Sharif MA: Postoperative complications in emergency versus elective laparotomies at a peripheral hospital. J Ayub Med Coll Abbottabad 2010, 22(3):42-47. 8. Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, Parry NG, Rozycki GS, Salomone JP, Tremblay LN: Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. The Journal of trauma 2003, 55(6):1095-1108; discussion 1108-1010. 9. Parmar G, Gohil A, Hathila V: Burst Abdomen–A Grave Postoperative Complication. The Internet Journal of Surgery 2009, 20(1). 10. Afzal S, Bashir MM: Determinants of Wound Dehiscence in Abdominal Surgery in Public Sector Hospital. Annals of King Edward Medical University 2010, 14(3). 11. Waqar SH, Malik ZI, Razzaq A, Abdullah MT, Shaima A, Zahid MA: Frequency and risk factors for wound dehiscence/burst abdomen in midline laparotomies. J Ayub Med Coll Abbottabad 2005, 17(4):70-73. 12. Bucknall TE: Factors influencing wound complications: a clinical and experimental study. Annals of the Royal College of Surgeons of England 1983, 65(2):71-77. 13. Hoer J, Lawong G, Klinge U, Schumpelick V: [Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 2002, 73(5):474-480. 14. Mudge M, Hughes LE: Incisional hernia: a 10 year prospective study of incidence and attitudes. The British journal of surgery 1985, 72(1):70-71. 15. Conze J, Klinge U, Schumpelick V: [Incisional hernia]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 2005, 76(9):897-909; quiz 910. 16. DiPiro JT, Martindale RG, Bakst A, Vacani PF, Watson P, Miller MT: Infection in surgical patients: effects on mortality, hospitalization, and postdischarge care. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 1998, 55(8):777-781. 17. Ussiri E, Mkony C, Aziz M: Sutured and open clean-contaminated and contaminated laparotomy wounds at Muhimbili National Hospital: A comparison Of complications. 2004. 18. Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS et al: Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. The American journal of medicine 1991, 91(3b):152s-157s. 19. Scott PG, Chambers M, Johnson BW, Williams HT: Experimental wound healing: increased breaking strength and collagen synthetic activity in abdominal fascial wounds healing with secondary closure of the skin. The British journal of surgery 1985, 72(10):777-779.

Conclusion
Our results indicate that most of the laparotomies conducted at CHK are emergency in nature. Complication rate is very high in both emergency and elective cases. As such, timely measures need to be taken in order to decrease the frequency of post-op complications.

Limitations
Patients who developed complications as a result of the parent laparotomy but were not admitted to CHK were not included in this study. Patients who passed away after discharge were also not mentioned. All patients could not be followed up via phone or email because of lack of resources.

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23. Nursal Tarık Z, Ataç B, Hasan A, Ömer A: Factors affecting healing of enterocutaneous fistulas. Turkish Journal of Gastroenterology 2000, 11(3):222226. 24. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, Ivatury RR, Scalea TM: Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. The Journal of trauma 2010, 68(3):721-733.

20. Berry SM, Fischer JE: Classification and pathophysiology of enterocutaneous fistulas. The Surgical clinics of North America 1996, 76(5):1009-1018. 21. Fischer PE, Fabian TC, Magnotti LJ, Schroeppel TJ, Bee TK, Maish GO, 3rd, Savage SA, Laing AE, Barker AB, Croce MA: A ten-year review of enterocutaneous fistulas after laparotomy for trauma. The Journal of trauma 2009, 67(5):924-928. 22. Edmunds LH, Jr., Williams GM, Welch CE: External fistulas arising from the gastro-intestinal tract. Annals of surgery 1960, 152:445-471.

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Factors influencing the choice of a medical specialty

Open Access
Factors influencing the choice of a medical specialty among medical students
Areeba Saif1, Syed Askari Hasan1, Tahrim Farrukh1, Najla Khan1, Hira Batool1, Tooba Baqai1

Original Article

Abstract
Background: The choice of a medical specialty by a medical student is a complex process in which several factors play a contributory role, making the decision process an evolving one as the medical student undergoes different experiences in his/her professional journey. In our study, we attempted to identify factors that play a significant role in influencing medical students towards choosing a specialty and also to delineate the differences that exist amongst students’ priorities based on gender and year of study at a medical university. Methods: This was a cross-sectional survey conducted on the medical students enrolled at Dow Medical College. Students from all five years of the medicine program were randomly selected. A self-administered questionnaire based on 16 questions was designed. The first part comprised of bio-data and specification of the choice of career by the participants. The second part comprised 13 factors influencing students’ choices, that were to be rated by the students in the order of their importance. Mann Whitney test, Kruskal Wallis test and Tukey’s test was performed for comparison. Results: Out of 400 candidates that successfully completed the study, all except one planned to specialize in one of the three major fields. 233 (58.4%) students wanted to pursue medicine, 156 (39.1%) surgery and only 10 (2.5%) wanted to adopt research as their career. Significant differences were found in working hours, duration of residency and influence during clinical rotations between the two specialties. Conclusion: These findings re-enforce the recently evolving idea that all disparities existing between different specialties should be resolved so as to ensure an equal spread of doctors in all fields. There is also a need to introduce more female friendly legislations and more incentives need to be offered to medical graduates to prompt more of them to choose a future career in research. (El Med J 1:2; 2013) Keywords: Medical Education, Specialty, Medical Students, Pakistan

Introduction
The choice of a medical specialty by a medical student is a complex process in which several factors play a contributory role, making the decision process an evolving one as the medical student undergoes different experiences in his/her professional journey. Some specialties require doctors to be focused on specific regions of the human body or to learn particular skills, while others require a broader perspective with the doctor’s focus being on the entire patient as a whole. Furthermore, non-clinical activities, such as academics and research come with their own sets of requirements. The choice to pursue any of those avenues is a very individualized one and many factors influence it [1]. While there is much literature present on evaluating personalities of individuals and the part individual personalities play in the choice of a specialty, others factors, such as social, family, financial, psychological factors are yet to be researched [2-4]. Furthermore, in a developing country like Pakistan, where cultural and social restraints play a great role in influencing the choice of medical students, especially those belonging to the female gender, there is a great need for research in this area as currently the distribution of males and females in many specialties such as gynecology and surgery is not uniform, consequently leading to a wide gap between the numbers of patients and doctors in a particular medical field. Additionally, it has been observed that in Pakistan there is a significantly low trend in medical students opting for careers in research or academics. This non-uniform distribution of specialties in Pakistan has long been a matter of concern. Hence attention needs to be focused on factors

affecting medical students’ choices as these are essentially responsible for the pattern of specialty distribution in a country [5-6]. The knowledge of factors influencing the choice of medical specialty in medical students shall pave the way for assisting students in choosing the right specialty for them and will also help remedy the non-uniformity of specialty distribution. Moreover this needs to be studied right from the beginning of a medical student’s academic journey as it has been found that most medical students make career choices early on in their academic lives and these remain stable throughout their undergraduate and post graduate years [6-10]. In our study, we attempted to identify factors that play a significant role in influencing medical students towards choosing a specialty and also to delineate the differences that exist amongst students’ priorities based on gender and year of study at a medical university.

Methods
This was a cross-sectional survey conducted on the medical students enrolled at Dow Medical College. Students from all five years of the medicine program were randomly selected to be included in the study. A sample size of 400 was computed using Open-EPI® calculator with a population size of 2000, response distribution of 50%, margin of error of 5% and confidence interval of 95%. The resultant sample size was therefore 462. A self-administered questionnaire based on 16 questions was designed. The first part comprised of bio-data (name, age, gender, year of study) and specification of the choice of career by the participants. Three options: “medicine and its subspecialties”, “surgery and its

1

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Syed Askari Hasan Email: askari_hasan2004@hotmail.com
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Saif A, Hasan SA, Farrukh T et al.

33 wanted to pursue medicine, 156 (39.1%) surgery and only 10 (2.5%) wanted to adopt research as their career. The percentage of male students opting for surgery and medicine was approximately fifty percent each but more female students preferred medicine over surgery (65% and 35% respectively). Comparing the influence of different factors in leading to the choice of medicine or surgery as a specialty, significant differences were found in working hours (p<0.001), duration of residency (p=0.03) and influence during clinical rotations between the two specialties. 146 (62.7%) people out of 233 who chose medicine as a specialty of choice rated working hours as one of the most important factors in their consideration, whereas 63 (40.4%) out of 156 people who chose surgery rated it as one of the most important factors. As for duration of residency, 121 (51.93%) people said it was one of the most important factor in their consideration for choosing medicine as a specialty while 58 (37.18%) people stated that duration of residency influenced their choice of surgery as a specialty. 68.7% of those who chose medicine as a specialty were influenced during their rotations while 56.4% of participants interests in surgery ranked it as an important factor. When factors were compared according to the year of study in medical university using the Kruskal Wallis test statistically significant differences in opinion among the students belonging to each of the five years were found for factors - family Influence, working hours, income, scope, personal interest, influence during electives and duration of residency. See Table 1 for details. We also compared the results obtained from final year students with those from each of the other four years’ students and found significant differences in family influence (p<0.001) between final year and first year students, in working hours (p=0.006) between final year and third year students, in income (p=0.010) between first year and final year students, in personal interest (p= 0.004) between final year and third year students, in influence during clinical rotation

subspecialties” and “research and academics” were specified. The second part comprised 13 factors influencing students’ choices, that were to be rated by the students in the order of their importance. A five point scale was devised with 1 being most important and 5 being least important on the scale. The factors included were family influence, working hours, income, personal interest, scope of specialty in Pakistan, fewer opportunities in the field of choice, ability to serve better, peer pressure, inspirational personality or role models in the desired field, influence during clinical rotation, duration of the residency program and how challenging the field was. After approval from the Institutional Review department of Dow University of Health Sciences the questionnaire was distributed among the students. Data collection stretched over a 4 month period. Data analysis was performed using Statistical Package for Social Sciences version 16.0. The importance of the factors as rated by the students was divided into three classes: scores 1 and 2 were group together as most important, scores 3 and 4 were slightly important and score 5 was classified as not important. The choice of major specialty among students was compared according to the year of study and gender. The factors influencing the specialty preferences were compared between the two genders by using Mann Whitney test. Also, the Kruskal Wallis test was conducted to compare each factor among the years of study. Tukey’s test was performed for the multiple comparisons in students of all five years of medical university. Kruskal Wallis was also applied to observe differences in factor preferences between all three major specialties and Tukey’s test was used to see the pair-wise differences within the three groups.

Results
400 out of a total of 462 candidates successfully completed the study, giving a response rate of 86.6%. Out of these, 115 were males (29%) and 282 females (71%), while 3 students chose not to specify their gender. From each year, the proportion of students was approximately one fifth of the sample size. All except one planned to specialize in one of the three major fields. 233 (58.4%) students

Table 1: Kruskal Wallis test – Year of study wise comparison of factors influencing choice of specialty 1st Year 2nd Year 3rd Year Most Not Most Not Most Not Factors Important Important Important Important Important Important Family Influence 57 15 28 15 29 10 Working Hours 47 6 41 11 24 3 Income 69 1 54 3 49 4 Scope 72 4 43 5 41 8 Fewer specialists in field 34 11 30 3 29 12 Personal Interest 82 2 70 4 58 4 Ability to serve better 75 2 62 3 56 0 Peer Pressure 23 30 8 35 12 27 Inspirational Personality 39 18 28 15 37 14 Residency availability overseas 43 15 42 10 43 10 Influenced during electives 48 18 45 6 40 5 Duration of Residency 47 10 32 13 20 12 How Challenging field is 58 4 18 1 48 2

4th Year Most Not Important Important 38 18 50 7 57 2 45 10 27 11 72 0 69 0 12 33 39 10 38 17 58 4 39 6 51 7

5th Year Most Not Important Important 26 25 54 5 47 7 54 2 34 12 81 0 77 0 10 33 39 14 38 19 63 5 46 8 63 2

P-value 0.002 0.009 0.026 0.004 0.707 0.012 0.14 0.197 0.457 0.251 0.004 0.006 0.248

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34 Table 2: Tukey’s test - difference of choice between final and other years Factors 5th vs 1st 0.000 Family Influence Working Hours Income Personal Interest Scope Influenced during electives Duration of residency (p=0.007) between final year and first year students and in duration of residency (p=0.009) between third year and final year students. See table 1 and 2 for more details. Given below are the figures obtained for every individual factor and also gender differences in scoring for each of the 13 factors mentioned in our questionnaire. Also refer to table 3 for a gender-wise comparison of the factors affecting choice of specialty. Family Influence A total of 178 (44.5%) participants scored family influence as one of the most important factors, 138 (34.5%) as slightly important and 83 (20.8%) as not important at all. Out of 115 males included in the study, 50 males rated it as an important factor for their choice of medical specialty while 34 males rated it as an insignificant one. On the other hand, 127 females considered it to be most important factor while 48 females said that it played no part in their choice of a medical specialty. No statistically significant difference in males and females was found. 0.563 0.010 0.833 0.197 0.007 0.995

Factors influencing the choice of a medical specialty

5th vs 2nd 0.764 0.403 0.233 0.689 0.887 0.242 0.316

5th vs 3rd 0.304 0.006 0.432 0.004 0.860 0.144 0.009

5th vs 4th 0.239 0.991 0.186 0.446 0.716 0.997 0.978

Working hours 216 (54%) participants rated working hours as one of the most important factors, while 151 (37.8%) rated it as slightly important and 32 (8%) rated it as not important at all. Only 21 (18%) male participants rated working hours as an unimportant factor in their consideration for choice of specialty while 51 (44.3%) males considered it to be the most important factor. In contrast, 165 females (57.89 %) females considered working hours to influence their choice while 20 females (7%) did not accord any importance to this factor. The difference in males and females was found to be statistically significant. Income When income was analyzed, it was found 276 (69%) people considered it as one of the most important factors while 105 (26.2%) considered it slightly important and 17 (4.2%) considered it not important at all. 84 males chose income as the most important factor while 5 chose it to be the least important factor. Amongst females, 190 believed income to be the most important while 12 believed it

Table 3: Mann Whitney test: Factors affecting choice of specialty – a gender wise comparison Males Females Factors Most Important Not Important Most Important Not Important Family Influence 50 (43%) 34 (30%) 127 (45%) 48 (17%) Working Hours 51(44%) 21 (18%) 165 (59%) 20 (7%) Income 84 (73%) 5 (4%) 190 (67%) 12 (4%) Scope 71(62%) 11 (10%) 183 (65%) 23 (8%) Fewer specialists in field Personal Interest Ability to serve better Peer Pressure Inspirational Personality Residency availability overseas Influenced during electives Duration of Residency How Challenging field is 55 (48%) 98 (85%) 97 (84%) 17 (15%) 59 (51%) 69 (60%) 65 (57%) 38 (33%) 70 (61%) 11 (10%) 2 (2%) 2 (2%) 50 (43%) 22 (19%) 18 (16%) 14 (12%) 16 (14%) 6 (5%) 99 (35%) 262 (93%) 241 (85%) 48 (17%) 121 (43%) 133 (47%) 187 (66%) 146 (52%) 206 (73%) 36 (13%) 8 (3%) 3 (1%) 106 (38%) 49 (17%) 53 (19%) 24 (9%) 32 (11%) 10 (4%)

P-value 0.164 0.009 0.264 0.507 0.024 0.027 0.703 0.302 0.339 0.04 0.056 0.002 0.013

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35 (36%) scored it as slightly important and 71 (17.8%) rated it as least important. When gender was separately analyzed 59(51%) males reported to it to be the most important factor for them while 22(19%) rated it as the least important factor. 48(17%) females reported it to be most important on their list while 106(38%) considered it the least important factor. No significant difference in males and females was found (p = 0.339). Residency opportunities overseas When residency in US or UK was analyzed as an influencing factor, it was seen that out of a total of 399 respondents 204 (51%) rated it as most important factor, 124 (31%) rated it as slightly important and 71 (17.8%) rated it not important. When analysis was done on basis of gender, 69 (60%) males rated it as most important and 18 (16%) males said it was least important. 133 (47%) females considered it most important and only 53 (19%) considered it as least important factor. A significant difference in males and females was found (p=0.04). Influenced during Clinical Rotations When clinical rotations and electives as a factor was analyzed, it was found to be most important for 254 (63.5%) people, slightly important for 107 (26.8%) and not important for 38 (9.5%). When gender was separately analyzed, 65 (57%) males rated it as most important and 14 (12%) males rated it as least important. Out of females, 187 (66%) said it was one of the most important factors while 24 (9%) said it was the least important factor. The difference between males and females was found not to be significant. Duration of Residency Duration of residency as a factor was analyzed, it was found to be most important for 184 (46%) people, slightly important for 166 (41.5%) and not important for 49 (12.2%). When gender was separately analyzed, 38 (33%) males rated it as most important and 16 (14%) males rated it as least important. Out of females, 146 (52%) said it was one of the most important factors while 32 (11%) said it was the least important factor. The difference between males and females was found significant (p=0.002). How challenging the field is When as a factor whether a challenging field influenced students was analyzed, it was found to be most important for 277 (69.2%) people, slightly important for 105 (26.2%) and not important for 16 (4%). When gender was separately analyzed, 70 (61%) males rated it as most important and 6 (5%) males rated it as least important. Out of females, 206 (73%) said it was one of the most important factors while 10 (4%) said it was the least important factor. The difference between males and females was found significant (p=0.013).

to be the least important factor. No significant difference between males and females was found in our analysis. Scope When scope for a specialty as a factor was analyzed 255 (63.8%) respondents scored it as one of the most important factors, 110 (27.5%) scored it as slightly important and 34 (8.5%) rated it as least important. When gender was separately analyzed 71 males reported to it to be the most important factor for them while 11 rated it as the least important factor. 183 females reported it to be most important on their list while 23 considered it the least important factor. No significant difference in males and females was found. Fewer Specialists in a particular specialty When the presence of fewer specialists in a particular field was analyzed as a motivating factor for participants to choose a specialty, 154 (38.5%) people rated it as the most important factor, 192 (48%) rated is as slightly important and 49 (12.2%) people rated it as not important at all. 55 (48%) males rated it as the most important factor and 11 (10%) males rated it as the least important factor. Out of all females, 99 (35%) marked it as the most important factor and 36 (13%) marked it as the least important factor. This difference was found to be statistically significant (p=0.024). Personal Interest When personal interest as a factor was analyzed, it was found to be most important for 363 (90.8%) people, slightly important for 25 (6.2%) and not important for 10 (2.5%). When gender was separately analyzed, 98 (85%) males rated it as most important and only 2 (2%) males rated is as least important. Out of females, 262 (93%) said it was one of the most important factors while 8 (3%) said it was the least important factor. The difference between males and females was found to be statistically significant (p=0.027) Ability to serve better Analyzing ability to server better in a field as a motivating factor, we found it was one of the most important factors for 154 (38.5%) people, slightly important for 192 (48%) people and not important for 49 (12.2%) people. 97 (84%) males rated it as an important factor while 2 (2%) said it was not important. On the other hand, amongst females 241 (85%) said it was an important factor and 3 (1%) said it was not important Peer Pressure. There was no statistically significant difference. Ability to serve better When peer pressure as a factor was analyzed, it was found to be most important for 65 (16.2%) people, slightly important for 171 (42.8%) and not important for 158 (39.5%) people. When gender was separately analyzed, 17 (51%) males rated it as most important and 50(43%) males rated it as not important. Out of females, 48(17%) said it was one of the most important factors while 106(38%) said it was the least important factor. The difference between males and females was not found to be statistically significant. Inspirational Personality in a Field When it was analyzed that whether an inspirational personality influences students to make their choice it was found that 182 (45.5%) respondents scored it as one of the most important factors, 144

Discussion
Training after graduation in medicine is no longer a matter of choice but has become a necessity in the cut-throat competitive world we live in today. Thus, the findings in our study where all apart from one participant planned to pursue some kind of specialization are very encouraging. Most respondents in our study chose medicine and its allied branches as opposed to surgery as their chosen field of specialization. This is consistent with findings elsewhere in the world,
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36 where there has been a decline in medical graduates choosing surgery as a specialty possibly due to more demanding working hours, lack of flexibility of schedule and a more rigorous training program [11-13]. Moreover, we also observed a lesser number of women inclined towards surgery as compared to men. This could again be explained by the same reasons cited above, which affect women to a greater degree than men; also there’s a common perception amongst women about surgery being a male dominated field [14]. Interestingly, we observed a steady decline in the number of students interested in surgery over the five years of medical school. Khader et al reported a similar trend in their study [6]. A possible explanation for this could be that as younger medical students have lesser clinical exposure and are not aware of the rigors of surgical post-graduate training, their choice of surgery is based more on the ‘glamor and prestige’ associated with it. In our study, significant differences existed in areas of working hour preferences, duration of residency program between medicine and surgery and influence during clinical rotations. Working hours are considered to be more flexible in medicine and the duration of training programs in Internal Medicine is shorter than that in General Surgery and other surgical specialties. Hence those participants who chose medicine as a specialty rated these two factors higher on their list of preferences than those in surgery. It has been reported in literature that students during their IM clerkships are also highly likely to be influenced by their experience and hence this factor plays a significant role in their consideration for choosing IM and its sub-specialties as careers of choice [15-16]. As was expected, a disappointingly low number of participants (2.5%) chose to pursue careers in research after graduation. While financial constraints and lack of resources for research are cited as the most common reasons, there is no verified literature on the subject and assessment of these factors is imperative if Pakistan is to improve its standing in the research and academic field. According to the participants, personal interest most strongly influenced their choice of research as a career with 9 out of 10 people rating it as the most important factor, a finding consistent with other reported literature [17]. Park et al, in a study conducted to determine medical students’ attitudes towards pursuing a career in research, found that social and financial reasons played a great role in discouraging students from pursuing a career in this field [18]. Our findings support this view as most participants who chose research did not rate income and scope of research high on their lists of preferences. This may also explain why despite an interest and involvement in research activities during undergraduate training years as has been reported by several studies, most students do not consider research a serious career choice [19-21]. Amongst all factors, personal interest in the desired field of specialization was most highly rated by the respondents. When gender differences were analyzed, more females were likely to consider personal interest as one of the most important factors as compared to males. Males have greater financial concerns than females and are hence more likely to consider job security, income and scope along with personal interest [6]. Significant differences in opinions between final years and third years were found, with lesser number of third years considering personal interest as an important factor. This

Factors influencing the choice of a medical specialty

could perhaps be because in our system clinical clerkships begin in third year and at that point students are introduced to a wide array of choices and are hence undecided as to what they may be interested in. Final year students on the other have had experiences of all specialties and hence are in a better position to determine their personal interests. The second most highly rated factor in our study was the participants’ feeling that they could serve better and succeed more in the field they chose. This idea of being a ‘personal fit’ in a specialty and being most suited to it has also been reported in other studies [2223]. Whether a specialty was challenging or not was also one of the highly rated factors, with almost 69% participants considering it as one of the most important factors. A great number of respondents also rated being influenced during clinical clerkships highly. This reenforces the idea that those years in a medical student’s life are pivotal in shaping his/her career choice and much focus needs be given to those formative years in recruiting graduates to a particular field [24-25]. When working hours are considered the statistically significant difference between males and females in our study is consistent with the current social trends in Pakistan, where females are expected to choose a less demanding specialty as far as working hours and a controllable lifestyle are concerned. Our findings, however, were inconsistent with most statistics reported in literature elsewhere in the world, where controllable lifestyles and easy working hours are fast becoming one of the most important factors contributing to the choice of a medical specialty [26-27]. Several other factors including personal interest and ability to serve better in the chosen field were rated higher by both males and females. Income and scope, although not the most highly rated factors in our study, were chosen by a sufficiently high number of participants as important factors. Most studies report income to be a highly significant deciding factor for most medical students and graduates alongside flexible working hours and controllable lifestyles [3, 27-29]. In Pakistan, there has been a consistent increase in the number of medical graduates opting for post-graduate training overseas each year. Hence, opportunities for residencies overseas are an important consideration for medical students [30-31]. Greater than 50 percent participants of our study therefore reported this as one of the most important deciding factors. Moreover, a significantly higher number of males scored it as an important factor as they are more inclined than females to consider opportunities overseas in our set-up. Analyzing family influence as a contributory factor in medical students’ choices reveals expected results when a year wise comparison is made. More first years weigh family influence heavily in their choices versus final year students, as in our setup, up to a certain age, most academic decisions of children are controlled by their parents. On the other hand, it was expected that more females would be likely to be influenced by their families in their choices, as is believed to be the case in Pakistan; but in our study we found no difference existed between males and females.

Vol 1, No 2

Saif A, Hasan SA, Farrukh T et al.

37 medical students during undergraduate and post-graduate years can be made.

Several studies have found role models to play a significant role in determining medical students’ career choices [2, 25, 32-34]. However, in our study the presence of an inspirational personality or a role model did not configure highly in a medical student’s choice of specialty. This is an area that needs to be looked into further in order to provide students with role models to encourage them to pursue particular specialties. We found significant gender differences when studying working hours, personal interest, overseas residency opportunities primarily in UK and USA, duration of the residency, fewer specialists in the desired field of specialization and how challenging the field is. Most of these differences are predictable and some have already been discussed above. Males, with greater financial responsibilities on their heads are more inclined to consider working hours, overseas residency opportunities and a greater need of specialists in a field which roughly translates to greater job opportunities. Females on the other hand are more likely to consider personal interest, a shorter duration of residency and a less challenging field as more important factors [6, 35]. Family Influence, working hours, income, scope, influence during electives and duration of residency also showed a significant difference in year-wise analysis. Most of these are understandable when student exposure during clerkships is considered, as final year students, who have had a significant exposure to various specialties, are likely to have different opinions as opposed to the first and second year students, who have had no clinical exposure as yet. Particularly when final years and first years were compared we found differences in family influence, income and influence during clinical clerkships. While differences in family influence and influence during clinical rotations/clerkships have already been explained, it is postulated that the dissimilarity in income can be due to the fact that first years enter the medical university with a more idealistic view of the profession, while final year students with their greater exposure to the financial sufferings of people in a poverty stricken public sector hospital like ours, have more empathy and hence rate income lower on their list of preferences. However, this can only be proven with more research in this area to specifically analyze income preferences between the two years. The disparity in the male female distribution in public sector medical universities could be one of the limiting factors in our study in studying gender differences in preferences for medical specialties. Also, significant differences in preferences may exist among students of public and private medical universities in the city. Perhaps a bigger sample size representing a more balanced number of males and females and inclusive of all spectrums of medical universities would resolve these limitations. Also a more in-depth analysis of the decision process employed by students with the help of focus groups is required to come to a definite conclusion on determining the most important factors influencing choices of medical specialties. Future research in this area should attempt to dissect the stereotypes that exist in career choices presently, especially between the male and female gender. More comprehensive studies analyzing all contributory factors need to be conducted with the addition of a prospective follow-up system through which all changes in opinions of

Conclusion
These findings re-enforce the recently evolving idea that all disparities existing between different specialties including the huge differences in incomes and flexibility of working hours should be resolved so as to ensure an equal spread of doctors in all fields. Also, to encourage more females in pursuing challenging and more demanding fields, there is a need to introduce more female friendly legislation including reasonable maternity leaves, flexible working hours etc. Moreover, the lack of interest amongst medical students in pursuing careers in research and academics needs a more thorough analysis; accordingly, more incentives need to be offered to medical graduates to prompt more of them to choose a future career in research.
Competing interests: The authors declare that no competing interests exist. Received: 2 April 2013 Accepted: 9 July 2013 Published Online: 13 July 2013

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19. Vujaklija A, Hren D, Sambunjak D, Vodopivec I, Ivanis A, Marusic A, Marusic M: Can teaching research methodology influence students' attitude toward science? Cohort study and nonrandomized trial in a single medical school. J Investig Med 2010, 58(2):282-286. 20. Pruskil S, Burgwinkel P, Georg W, Keil T, Kiessling C: Medical students' attitudes towards science and involvement in research activities: a comparative study with students from a reformed and a traditional curriculum. Med Teach 2009, 31(6):e254-259. 21. Hren D, Lukic IK, Marusic A, Vodopivec I, Vujaklija A, Hrabak M, Marusic M: Teaching research methodology in medical schools: students' attitudes towards and knowledge about science. Med Educ 2004, 38(1):81-86. 22. Burack JH, Irby DM, Carline JD, Ambrozy DM, Ellsbury KE, Stritter FT: A study of medical students' specialty-choice pathways: trying on possible selves. Acad Med 1997, 72(6):534-541. 23. Rehman A, Rehman T, Shaikh MA, Yasmin H, Asif A, Kafil H: Pakistani medical students' specialty preference and the influencing factors. J Pak Med Assoc 2011, 61(7):713-718. 24. Al-Heeti KN, Nassar AK, Decorby K, Winch J, Reid S: The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career. J Surg Educ 2012, 69(4):544-549. 25. Stagg P, Prideaux D, Greenhill J, Sweet L: Are medical students influenced by preceptors in making career choices, and if so how? A systematic review. Rural Remote Health 2012, 12:1832. 26. Schwartz RW, Jarecky RK, Strodel WE, Haley JV, Young B, Griffen WO, Jr.: Controllable lifestyle: a new factor in career choice by medical students. Acad Med 1989, 64(10):606-609.

Factors influencing the choice of a medical specialty

27. Newton DA, Grayson MS, Thompson LF: The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004. Acad Med 2005, 80(9):809-814. 28. Patel MS, Katz JT, Volpp KG: Match rates into higher-income, controllable lifestyle specialties for students from highly ranked, research-based medical schools compared with other applicants. J Grad Med Educ 2010, 2(3):360-365. 29. Gorenflo DW, Ruffin MTt, Sheets KJ: A multivariate model for specialty preference by medical students. J Fam Pract 1994, 39(6):570-576. 30. Syed NA, Khimani F, Andrades M, Ali SK, Paul R: Reasons for migration among medical students from Karachi. Med Educ 2008, 42(1):61-68. 31. Imran N, Azeem Z, Haider, II, Amjad N, Bhatti MR: Brain Drain: Post Graduation Migration Intentions and the influencing factors among Medical Graduates from Lahore, Pakistan. BMC Res Notes 2011, 4:417. 32. Sternszus R, Cruess S, Cruess R, Young M, Steinert Y: Residents as Role Models: Impact on Undergraduate Trainees. Acad Med 2012, 87(9):1282-1287. 33. Ambrozy DM, Irby DM, Bowen JL, Burack JH, Carline JD, Stritter FT: Role models' perceptions of themselves and their influence on students' specialty choices. Acad Med 1997, 72(12):1119-1121. 34. Henderson MC, Hunt DK, Williams JW, Jr.: General internists influence students to choose primary care careers: the power of role modeling. Am J Med 1996, 101(6):648-653. 35. Weissman C, Zisk-Rony RY, Schroeder JE, Weiss YG, Avidan A, Elchalal U, Tandeter H: Medical specialty considerations by medical students early in their clinical experience. Isr J Health Policy Res 2012, 1(1):13.

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Open Access

Short Report

Opinions of medical students regarding prolongation of mechanical ventilation versus unassisted death
Zehra Aqeel Nizami1, Neha Aijaz1, Khushbakht Nargiza1, Ghazal Arif Siddiqui1, Ayesha Rida1, Omama Shakeel1, Iqra Irfan1, Anita Ghazal1, Maryam Kaukab1, Fatima Iqtidar1, Javeria Siddiqui1, Asna Sultana1, Nida Shafi1, Masood Abro1, Safdar Bhutto1

Abstract
Background: Mechanical ventilation is the process of supporting respiration by manual or mechanical means when normal breathing is inefficient or has stopped. The aim of our study was to determine the attitudes, knowledge, and opinions of medical students regarding prolongation of mechanical ventilation versus death without respiratory support. Findings: This was a cross-sectional study carried out at two academic institutions in Karachi for a period of three months. A total of 500 questionnaires were analyzed. The survey consisted of questions about the students' attitudes towards ventilators, their indications, mechanism of action, benefits, ethical issues surrounding their use, definition of brain death, and finally their personal opinion regarding what should be preferred: natural death, or respiratory support in critically ill patients. Majority (76.8%) had a ‘positive’ attitude towards ventilator-assisted life support. 406 (81.2%) students were of the view that ventilator is a machine that provides mechanical ventilation only, whereas 88 (17.6%) considered it to be an absolute life support machine. 219 (43.8%) believed that its usage was in accordance with religious and ethical values, 48 (9.6%) were not in agreement whereas 233 (46.6%) were not sure. 189 (37.8%) said that it was feasible to remove ventilation if the patient was considered brain dead, 232 (46.4%) said that guardian’s consent should be preferred, 29 (5.8%) supported ventilator’s continuation and 50 (10%) were not sure. 126 (25.2%) believed that immediate death would result on the removal of ventilator, 245 (49%) thought that patient would survive but would develop complications, whereas 129 (25.8%) were of the view that the survival would be without complications. Only 315 (63%) were successfully able to distinguished euthanasia from terminal weaning. Conclusion: The results of our survey indicate that most medical students prefer prolongation of mechanical ventilation over natural death. Special educational sessions aimed at increasing awareness regarding end of life practices is needed at college level. (El Med J 1:2; 2013) Keywords: Mechanical ventilation, Unassisted Death, Euthanasia, End of Life Practices

Introduction
Advancements in medical technology have led to the alleviation of a multitude of diseases, thereby extending lifespan. However, the impending benefits may also bring intricate choices for patients and their families. They may feel befuddled about their options for certain medical procedures. Some fear that they may have to undergo painful and expensive treatments, while others are of the view that they will not get the proper care they seek. Also, many moral ethical and religious issues have arisen as a result of these medical interventions. Many life-supporting machines are being used in this era, including but not limited to pacemakers, dialysis machine, mechanical ventilators and defibrillators. Out of these, mechanical ventilators are the most talked about life supporting machines, with controversial ethical and religious issues regarding their usage and withdrawal. A medical ventilator is any machine intended to mechanically move breathable air into and out of the lungs, to provide the mechanism of breathing for a patient who is physically unable to breathe or suffers from breathing insufficiency. They are usually used in short term procedures, but sometimes if a patient is critically ill, he might need it for life. Number of people dependent on ventilator has increased worldwide for the last decade due to advancement of medical techniques and preservation of life [1]. In Taiwan, ventilator need has accelerated by 70% among patients who are treated in ICU. Majority of these patients have become ventilator dependent [2]. However, just as every coin has two sides, there are cons associated with ventilator support as well. Research evidence suggests that ventilator carries

many risks, like patients becoming ventilator dependent, acquiring nosocomial infections, respiratory insufficiency etc [3]. Natural death means a patient should expire due to old age or disease, without medical intervening of life supporting machines, though the use of medications is continued. Patients do not have any compulsion to use medical treatments and may select to let a disease condition take its natural course. This becomes ethically questionable in some countries, especially when the patient is young and the treatment is simple and lifesaving, such as a blood transfusion for sudden severe loss of blood. Euthanasia is the deliberate causing or speeding of death in an individual with a medical condition that has been proven to be serious. In many countries, it is against the law. For euthanasia, the patient may either be aware, conscious and competent to make his own decisions or sometimes unaware and incompetent as in coma. Some people are of the view that switching off the ventilator is another form of euthanasia, but the topic is debatable. It is legitimate to switch off the ventilator in case where brain death has occurred, because in such condition, the ventilator is merely being utilized for a patient who is not likely to recover, thereby depriving others who may need it and also imposing significant financial burden in the process. There is also an increasing trend to discontinue ventilator in patients with severe respiratory support when they are marked as ventilator dependent for the rest of their lives. This condition is known as terminal weaning in which the ventilator is removed and the patient is allowed to die. There is no aid with death in this procedure; it just allows death to occur which would not be deferred if

1

Sindh Medical University, Rafiqui Shaheed Road, Karachi, Pakistan Correspondence: Zara Aqeel Nizami Email: zaara_aq@hotmail.com
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40 ventilator assisting machinery were not in place [4]. Therefore, mechanical ventilation is not a recommended treatment for those illnesses where there is little hope for survival and high chances of ventilation dependence. In such cases it is advised to issue a Do Not Resuscitate (DNR) order. A DNR order is an instruction written in a patient’s hospital chart indicating a doctor to avoid resuscitation incase the patient is in imminent risk of death. Usually a patient is worried about being put onto a ventilator when he signs a DNR. This signature shows that the patient has accepted that resuscitation would cause unnecessary agony and would not assuage the underlying illness. In his book “Clinical Ethics,” Jonsen states, “Therapists are hard pressed to accept that patients have the right to choose the manner in which they live or ultimately die. It is extremely difficult in many instances for a therapist to suppress their heroic instincts and respect a patient's wishes” [5]. Increasing costs for healthcare services, respect regarding patients' right for independence to treatment and recognition that extended ICU stays are frequently followed by fatality or disability have encouraged valuation of the benefits and inconveniences of intensive care and life-sustaining therapies. According to estimates, death rate is high among patients requiring lengthened mechanical ventilation: 33% to 44% of patients going through these treatments expire [6]. These incidents are more often associated with increased age, poor functional status before hospitalization and other co morbid conditions. Many people are of the view that mechanical ventilation is the last stage from where there are no chances of recovery. However, many examples are seen where not only the patient survives but lead a good life. Christopher Reeve, an eminent actor who performed the role of Clark Kent/Superman in the famous Superman movie, went on ventilation in 1995 and after almost 6 months, he was able to breathe again without ventilator. He lived for another 9 years and died in 2004 as a result of cardiac arrest. In one of the few studies that exist on the preference of ventilation over natural death, Mendelsohn et al interviewed survivors of prolonged mechanical ventilation after 12 months of discharge from the ICU. He was amazed to see that a good number of patients (86.5%) stated that they would opt to undergo mechanical ventilation again [8]. But the drawback of the study was that 48 hours or longer treatment was defined as prolonged mechanical ventilation not the usual 7 days or longer treatment. Hence, it remained unclear whether the patients who went through longer ventilated periods nurtured the same feelings or not. Options concerning ventilator support are a standard part of discussions with elderly people and their families when conferring end-oflife care. This is greatly influenced by faith in revival and the existence of age-related comorbid illnesses that might impact the prognosis. In the Framingham Heart Study, conducted by McCarthy and colleagues it was discovered that 63% of subjects over age 65 preferred to die than be sited on ventilator support to extend their life

Prolongation of mechanical ventilation versus unassisted death

[9]. Moreover, it was seen that adults who are pessimistic and dejected especially prefer to forego ventilator support in the case of a terminal illness [9]. Finley et al observed that African Americans and low-income individuals usually do not prefer ventilation, whereas non-Hispanic Whites, Mexican American and more affluent individuals prefer use of extensive life support including ventilator [10]. In contrast, Caralis et al observed that a group of younger Hispanics in Miami chose cardiopulmonary resuscitation and ventilator use more frequently than either Non-Hispanic Whites or African Americans [11]. The present study was conducted to explore the opinions of medical students regarding prolongation of mechanical ventilation versus unassisted death among clinically oriented students studying in Government Medical Colleges in Karachi.

Findings
A total of 500 questionnaires that encompassed medical students from Sindh Medical College and Dow Medical College were analyzed in order to assess the awareness among medical students about ventilators usage and its significance, and to extract their opinions regarding whether natural death should be preferred or ventilators should be used. The survey was conducted from June to August 2012. The survey consisted of questions about the students' attitudes towards ventilators’ indications, its working, and its benefits, ethical issues related to it, brain death and their personal opinion regarding what should be preferred in critically ill patients: natural death, or respiratory support. The results were analyzed using SPSS software. Out of 500 students, majority 384 (76.8%) had a ‘positive’ attitude towards ventilator life support: only a small proportion (23.2%) was in favor of unassisted death. Figure 1 gives a graphical representation of this data.
Attitudes of students regarding Mechanical Ventilation

116, 23% Prefer Against 384, 77%

Figure 1: Attitudes of Medical Students regarding Mechanical Ventilation 406 (81.2%) students believed that ventilator is a machine that provides mechanical ventilation only, whereas 88 (17.6%) considered it

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Table 1: Opinions of Medical Students regarding Mechanical Ventilation Respondents’ Institute What is a mechanical ventilator? Should natural death be preferred over mechanical ventilation in official guidelines? Under what circumstances should mechanical ventilation be allowed? What is the most important factor that leads to opting for natural death? In which condition you would prefer an assisted death for a patient who is on ventilator? What can be the most likely cause of removal of ventilator support? Do you think that doctors are able to take decisions about removal of ventilator support? What are your opinions regarding patient's survival after removing ventilator? The major reason for non-functional mechanical ventilation support systems in reputed Pakistani government hospitals is? Sindh Medical College Dow Medical College Respiratory Support Machine Life-saving Machine Anesthetic Machine No Idea Yes No Don’t Know Patient’s Own Request Doctor’s Advice Guardian’s Request Don’t Know Non-availability of ventilator Religious Issues Financial Problems False beliefs related to Mechanical Ventilation Unbearable Pain Financial Problems Doctor’s Advice Don’t Know Affordability Lack of Hope Confirmation of Brain Death Health Not Likely to Improve They are, without the guardian’s consent They are, but after taking consent from guardians They are, after consulting with senior colleagues They are not under any circumstances Healthy Life Survival without Complications Survival with Complications Immediate Death Mishandling Lack of Funds Untrained Technical Staff Political Reasons Frequency 411 89 406 88 2 4 206 293 1 77 336 64 23 130 112 200 58 214 44 107 135 66 91 265 78 105 296 29 70 52 77 245 126 47 334 91 28 Percentage 82.2% 17.8% 81.2% 17.6% 0.4% 0.8% 41.2% 58.6% 0.2% 15.4% 67.2% 12.8% 4.6% 26.0% 22.4% 40.0% 11.6% 42.8% 8.8% 21.4% 27.0% 13.2% 18.2% 53.0% 15.6% 21.0% 59.2% 5.8% 14.0% 10.4% 15.4% 49.0% 25.2% 9.4% 66.8% 18.2% 5.6%

to be an absolute life support machine. 219 (43.8%) thought that its usage is in accordance with the religious and ethical values, 48 (9.6%) were not in agreement while 233 (46.6%) were not sure. 189 (37.8%) responded that ventilation should be removed in brain dead patients, 232 (46.4%) said that guardian’s consent should be sought, 29 (5.8%) supported ventilator’s continuation and 50 (10%) were not sure. 126 (25.2%) expected immediate death after the removal of ventilator, 245 (49%) thought patient was likely to survive with complications, and 129 (25.8%) believed that the survival was without complications. Only 315 (63%) were successfully able to distinguished euthanasia from terminal weaning. Table 1 provides an overview of the responses to questions asked.

Discussion and Conclusion
Mechanical ventilation is indicated when the patient's spontaneous ventilation is inadequate to sustain life. In addition, it is indicated as a measure to control ventilation in critically ill patients, and as prophylaxis for impending collapse of other physiologic functions. Physiologic indications include respiratory or mechanical insufficiency, ineffective gas exchange and documented sleep apnea. There are not absolute contraindications for ventilator but possible contraindications are: Patients with severe respiratory failure without a spontaneous respiratory drive, hypotension, pre-existing pneumothorax or pneumomediastinum, acute sinusitis or otitis media, recent facial, oral or skull surgery or trauma etc.
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42 Despite their life-saving benefits, mechanical ventilators carry many risks. Therefore, the goal is to help patients recover as quickly as possible to get them off the ventilator at the earliest possible time. As ventilator is a life-saving machine, patients should avail the opportunity of ventilator as indicated by doctor. Measures should be taken or some aid should be provided to those patients who refuse to be on ventilator due to unaffordability. Weaning should be done by considering doctor's advice as well as consent of patient's family. One of the major limitations of our study was that it used only the opinions of medical students. Further researches should be conducted on experienced medical professionals and general populations. Few suggestions for further researches are: application of ventilator in developed and developing countries, Death rate due to unavailability of ventilators, to minimize abrupt withdrawal effects of ventilators and make it more beneficial. The results of our survey indicate that most medical students prefer prolongation of mechanical ventilation over natural death. Special educational sessions aimed at increasing awareness regarding end of life practices is needed at college level.
Competing interests: The authors declare that no competing interests exist. Received: 15 February 2013 Accepted: 15 July 2013 Published Online: 15 July 2013

Prolongation of mechanical ventilation versus unassisted death

References
1. Lindahl B, Sandman P-O, Rasmussen BH: On being dependent on home mechanical ventilation: depictions of patients' experiences over time. Qualitative health research 2006, 16(7):881-901. 2. Yang C-C, Shih N-C, Chang W-C, Huang S-K, Chien C-W: Long-term medical utilization following ventilator-associated pneumonia in acute stroke and traumatic brain injury patients: a case-control study. BMC Health Services Research 2011, 11(1):289. 3. de Abreu MG, Rocco P, Pelosi P: Pros and cons of assisted mechanical ventilation in acute lung injury. In: Annual Update in Intensive Care and Emergency Medicine 2011. edn.: Springer; 2011: 159-173. 4. Crippen D: Should This Patient Be Admitted to a Critical Care Unit? In: Three Patients. edn.: Springer; 2002: 163-175. 5. Jonsen AR, Siegler M, Winslade WJ, Siegler M, Winslade WJ: Clinical ethics: a practical approach to ethical decisions in clinical medicine: McGraw Hill, Medical Pub. Division; 2006. 6. Tobin MJ: Advances in mechanical ventilation. New England Journal of Medicine 2001, 344(26):1986-1996. 7. Niskanen M, Ruokonen E, Takala J, Rissanen P, Kari A: Quality of life after prolonged intensive care. Critical care medicine 1999, 27(6):1132-1139. 8. Mendelsohn AB, Belle SH, Fischhoff B, Wisniewski SR, Degenholtz H, Chelluri L: How patients feel about prolonged mechanical ventilation 1 year later. Critical care medicine 2002, 30(7):1439-1445. 9. McCarthy EP, Pencina MJ, Kelly-Hayes M, Evans JC, Oberacker EJ, D'Agostino RB, Sr., Burns RB, Murabito JM: Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study. The journals of gerontology Series A, Biological sciences and medical sciences 2008, 63(9):951-959. 10. Garrett JM, Harris RP, Norburn JK, Patrick DL, Danis M: Life-sustaining treatments during terminal illness: who wants what? Journal of general internal medicine 1993, 8(7):361-368. 11. Caralis PV, Davis B, Wright K, Marcial E: The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. The Journal of clinical ethics 1993, 4(2):155-165.

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Open Access
Overview of the role of atrial natriuretic peptide in cardiac pathophysiology
Syed Waqar Ali1, Ruba Ali Zahid1, Maheen Anwer1, Anum Saleem1, Syed Arsalan Ali1

Review

Abstract
Atrial natriuretic peptide is a 28 amino-acid peptide with a 17 amino-acid ring in its center. It is synthesized by myocytes in the cardiac atria. It plays a multitude of roles in the human body, with the cardiovascular effects being the most prominent. (El Med J 1:2; 2013) Keywords: Atrial natriuretic peptide, cardiovascular

Introduction1
Diseases affecting the cardiovascular system (CVDs) are the leading causes of death in the world, accounting for over 17.3 million deaths in 2008 [1]. Ischemic heart disease were responsible for 7.3 million deaths, whereas strokes were responsible for 6.2 million [1]. Lowincome and middle-income countries are disproportionally affected, as over 80% of CVD deaths occur in these countries. The disease process that encompasses the blood vessels, and is prominent in coronary heart disease and cerebrovascular disease, is known as atherosclerosis. The major underlying cause of atherosclerosis is hypertension, prevalent in nearly 30% of adults worldwide [2]. The underlying causes of hypertension are complex and varied. They include factors such as blood volume, vascular response, neurohormonal regulation and genetic variations. The disease is primarily a result of the body’s failure to adequately regulate salt and body fluid homeostasis [3-4]. Although the kidney occupies a central role in blood pressure regulation, the heart also plays its part, mainly via a cardiac hormone, atrial natriuretic peptide (ANP) [5-7]. In the following review we described the relationship of ANP with cardiovascular pathophysiology.

and blood vessels, thus promoting excretion of salt, lowering of blood volume and relaxation of the vessel, thereby lowering wall stress and also increasing the oxygen concentration of the blood [12]. The production and release of ANP by cardiac myocytes is triggered by an increase in pressure and/or myocardial wall stretch [13]. Neurohormonal factors such as cathecholamines, angiotensin II, endothelin and glucocorticoids may also influence its release [14]. It then binds to a receptor widely present on the surface of cells throughout the CVS: vascular smooth muscle, vascular endothelium, heart and kidneys [15]. These receptors are part of membrane-associated guanylyl cyclase receptor family (NPR) [15]. At least seven NPRs are known, of which NPR-A and NPR-B are responsible for the majority of the effects of natriuretic peptides [15]. Both ANP and BNP have a high affinity for binding to NPR-A, but ANP is more potent in receptor activation [15]. The binding of ANP to NPR-A (GC-A) leads to an increase in the intracellular second messenger cyclic Guanosine Monophosphate (cGMP), which in turn stimulates three known cGMP effector molecules: cGMP dependent protein kinases (PKGs), cGMP dependent phosphodiesterases (PDEs) and cGMP dependent ion channels [16]. These effector molecules are responsible for the physiologic effects on cGMP on the cardiovascular system [15]. Three processes most likely contribute to the clearance of ANP from the body: receptormediated degradation, degradation by extracellular proteases and secretion of the ANP into body fluids such as urine or bile [17]. Neutral endopeptidase (NEP) is one of the enzymes responsible for the degradation of ANP [18].

Methods
The Pubmed and Google Scholar indices were searched using the keywords “atrial natriuretic peptide”, “cardiovascular” and “pathophysiology” to assemble literature concerning this topic published in indexed journals over the past ten years. We also used the "related articles" function on PubMed which allowed us to search the references of the studies that were retrieved during our search. Publications were included in our review if either their titles or abstracts were available in English.

Physiologic Functions of ANP
Blood pressure and volume regulation An increase in blood pressure and volume lead to stretching of the cardiac atria. This stimulates the secretion of ANP by the atrial cardiac myocytes [13]. ANP acts on the cells of the blood vessels and kidneys to lower blood pressure and volume. ANP activates NPR-A receptors present in renal cells to generate cGMP. This leads to an increase in natriuresis and diuresis [19]. It also leads to an increase in the GFR and the filtration fraction [19]. In general, natriuretic peptides are counter-regulatory system to the renin-angiotensin-aldosterone axis [20]. Thus increased ANP leads to

Atrial Natriuretic Peptide
Atrial Natriuretic Peptide was discovered by deBold and colleagues in 1979 in Kingston, Ontario [8]. It is a 28 amino-acid peptide with a 17 amino-acid ring in its center. The ring is the result of a disulphide bond between two cysteine residues at positions 7 and 23. It is closely related to brain natriuretic peptide (BNP) and C natriuretic peptide (CNP). ANP. Atrial Natriuretic Peptide is a polypeptide hormone produced in the cardiac atria by atrial myocytes primarily due to increased atrial wall stress and hypoxia [9-11]. ANP binds to its receptors in the kidney
1

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Syed Arsalan Ali Email: syedarsalanali1@gmail.com
http://www.mednifico.com/index.php/elmedj/article/view/15

44 a decrease in renin production, which leads to a decrease in the levels of angiotensin II and aldosterone in the blood [19]. This leads to increased natriuresis and diuresis [19]. A decrease in angiotensin II also leads to systemic vasodilation and therefore decreased vascular resistance [19]. ANP also causes vasorelaxation. It does this by inhibiting the release of calcium in the smooth muscle cells of the blood vessels, as well as by decreasing calcium sensitivity of the smooth muscle cell contractile machinery [15]. All of the above factors additively contribute to a decrease in the blood pressure and volume. Fluid-electrolyte balance An increase in the fluid volume of the blood causes stretching of the right atrium. This stretching stimulates the secretion of ANP by the atrial myocytes, by a mechanism already explained above [13]. ANP then causes increased diuresis and natriuresis, which lowers the sodium concentration of the blood and thus decreases the blood volume [19]. ANP also suppresses the secretion of ADH, Aldosterone, Renin and Angiotensin II [20]. Thus, ANP plays an important role in maintaining fluid-electrolyte balance. Cardiomyocyte hypertrophy ANP serves as a marker of cardiac hypertrophy. Studies have shown that endogenous ANP regulates cardiomyocyte hypertrophy through its receptor guanylyl cyclase-A (GC-A) [21]. Mice lacking the GC-A receptor have been shown to have pronounced hypertension and cardiac hypertrophy [22]. Also, a recent study has shown that a functional deletion in the human GC-A gene and decreased receptor activity are associated with cardiac hypertrophy and essential hypertension [23]. ANP may also serve as an autocrine factor in regulating cardiomyocyte growth [24]. Role in vascular leakage and angiogenesis Atrial Natriuretic Peptide also plays an important role in preventing vascular leakage and regulating angiogenesis. The NP/GC-A system functions as a regulator of vascular regeneration in the heart and skeletal muscle [25]. It does this by increasing the proliferation of microvascular endothelial cells via activation of the kinase PKG I [25]. In a recent study, it was shown that the deletion of the GC-A gene in the endothelial cell of mice severely impaired vascular regeneration in response to hind limb ischemia [25]. Thus, ANP serves as a stressresponsive regulator of angiogenesis in the mouse hypertrophic heart and ischemic hind limb [25]. Low concentrations of ANP have also been shown to stimulate proliferation and migration of cultured human macrovascular endothelial cells [26]. The effects of ANP causing stimulation of endothelial regeneration occur independently of the VEGFA/VEGFR2 system [27]. In fact, ANP antagonizes the production and signaling of VEGF and has hence been shown to reduce VEGF induced vascular leakage, in vivo [27]. Metabolic role in adipocytes Recent studies show that ANP is involved in lipid metabolism. ANP has been shown to stimulate lipolysis, in vitro, in human adipocytes and locally in subcutaneous adipose tissue [28, 29]. It has also been shown to induce lipid mobilization in subcutaneous adipose tissue [30]. ANP acts on adipocytes by activating the NPR-A present on their plasma membranes which in turn increases the concentration of intracellular cGMP [31]. The cGMP then activates cGK-1, a kinase which induces the phosphorylation of hormone sensitive lipase (HSL) and
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Role of atrial natriuretic peptide in cardiac pathophysiology

perilipin A [31]. HSL then hydrolyzes the triglycerides present in the adipocytes into non-esterified fatty acids (NEFAs) and glycerol [31]. As such, intravenous infusions of ANP have been shown to dose-dependently increase plasma concentrations of NEFAs and glycerol [30].

Pathologic Role of ANP
Myocardial ischemia Myocardial ischemia has been shown to increase production of ANP in clinical and experimental studies [32]. There are currently two theories as to how myocardial ischemia potentiates the secretion of ANP in patients with hypertrophic cardiomyopathy. The first one states that the elevated left atrial stress caused by the myocardial ischemia may stimulate production of ANP [32]. However, recent studies suggest that myocardial ischemia directly stimulates secretion of ANP from the left ventricle via energy metabolic mechanism [32]. Secretion of ANP has been shown to attenuate ST-segment depression, myocardial lactate production and improve left ventricular function during pacing-induced ischemia [33]. It may also increase myocardial perfusion to the ischemic region, possibly by dilating coronary arteries and decreasing coronary vascular resistance [34]. Intravenous injections of ANP have also been shown to attenuate exercise-induced myocardial ischemia in patients with stable effort angina pectoris [34]. Myocardial infarction The occlusion of a coronary artery causes tissue ischemia progressing to myocardial infarction (MI) with death of cardiomyocytes [35]. Recent studies have shown that there is an increase in ANP and BNP mRNA early after infarction [36]. This causes a rapid secretion of ANP from the cardiomyocytes, and hence an increase in the plasma levels of ANP [36-38]. Studies have shown that the activation of GC-A receptor by endogenous ANP protects against heart failure and attenuates chronic cardiac remodeling after MI by inhibiting the renin-angiotensin system (RAS), although RAS-independent protective actions are also suggested [36]. Recent evidence suggests that a brief period of ischemia with reperfusion and prolonged ischemia following a myocardial infarction exhibit different patterns of gene and therefore protein expression [39]. In mice with experimental coronary artery occlusion without reperfusion, ANP increased formation of P-selectins and neutrophils infiltration hence increasing the size of the infarct and mortality [39]. However, pharmacologic doses of ANP given to humans with coronary artery occlusion undergoing coronary reperfusion reduced the infarct size, diminished dilation of the left ventricle and slightly improved heart function 30 days after treatment [39]. This is attributed to the fact that ANP increases coronary collateral blood flow and lowers end-diastolic pressure [39]. Heart failure: An indicator of severity, mortality and survival Congestive Heart Failure (CHF) is a clinical syndrome characterized by increased cardiac volume and pressure overload along with an inability to excrete a sodium load which leads to increased activation

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45 and bone tissue [50]. Recent evidence suggests that neurohormonal and muscle abnormalities play an important role in cardiac cachexia [50]. Obesity and metabolic syndrome Recent studies have shown that obese patients with hypertension and metabolic risk factors have reduced plasma levels of natriuretic peptides and/or an impaired natriuretic peptide response [51]. In such patients the BMI is inversely related to plasma natriuretic peptide levels [51]. Another recent study has shown that humans with low levels of ANP were more likely to develop Type II Diabetes Mellitus (T2DM) [52]. As such, obesity, insulin resistance and T2DM have all been associated with reduced levels of natriuretic peptides [52]. This study further reports that a high natriuretic peptide genotype is associated with low body weight and a decreased incidence of metabolic syndrome [52]. Also, it has been theorized that GC-A activation promotes lower weight, decreased calorie intake and catabolism [52]. Hypertension ANP is involved in the regulation of body’s sodium and water balance via regulation of natriuresis and diuresis along with the RAS [12]. A multitude of studies has shed light over the role of ANP in hypertension. For example, a study on ANP deficient mice showed that genetically decreased production of ANP leads to salt-sensitive hypertension [53]. Similarly, in transgenic mice, over-expression of ANP has also been found to be associated with hypotension [16]. In humans, several single nucleotide polymorphisms (SNPs) were found in the ANP gene, one of which (-C664G) was located in the promoter region. Genetic studies performed on -C664G demonstrate that the allele is associated with low levels of plasma ANP, high blood pressure and left ventricular hypertrophy [12]. Another mutation found in the ANP receptor gene, described as an 8-bp deletion mutation identified in the 5’-flanking region impaired promoter activity when tested in vitro, and was associated with hypertension and cardiac hypertrophy in a Japanese population [23]. Corin is a serine protease isolated from cardiomyocytes which converts pro-ANP into ANP [12]. A study performed on Corin deficient mice showed that systolic, diastolic and mean arterial blood pressures were considerably increased in these mice as compared to the normal controls [54]. The results were similar to the hypertension observed in ANP deficient mice [53]. Female Corin deficient mice exhibit hypertension during pregnancy, as the ability of Corin deficient mice to regulate high-salt diets is compromised [55]. Thus, pathologies that interfere with the ANP pathway such as genetic mutations may contribute to hypertension and cardiac disease. Mitral Regurgitation Mitral regurgitation (MR) is the leaking of blood back into the left atria when the left ventricle contracts due to impaired function of the mitral valve. Due to the back flow of blood from the ventricles into the atria, MR causes atrial stretching which leads to an increase in the levels of plasma ANP [54]. A study conducted on dogs with MR showed that their plasma ANP levels were significantly increased as compared to the normal controls [56]. This could be because ANP synthesis was altered and there was increased secretion of ANP from the heart in the dogs with MR [56].
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of systemic neurohormonal and local paracrine and autocrine factors [40]. Due to the increased synthesis and release of ANP in CHF, its circulating levels are greatly increased. Hence, ANP has emerged as an important diagnostic and prognostic serum marker in CHF [40]. Recent studies in patients with organic heart failure have shown that the levels of ANP are closely related to the severity of heart failure, being negatively related to the cardiac index and positively related to right/left atrial and pulmonary arterial pressures [41]. Central Sleep Apnea (CSA), a common feature in male CHF patients, is associated with increased morbidity and mortality. Studies have shown that low concentrations of ANP and BNP are associated with a low risk of CSA in men [42]. Coronary artery reperfusion Coronary artery reperfusion therapy is utilized in patients who have suffered from coronary occlusion leading to ischemia of the cardiac tissue. It has been shown to lead to a rapid recovery in the endocrine and mechanical function of the heart [43]. However, the reperfusion therapy itself has been shown to damage the myocardium [44]. In a recent study conducted on dogs, atrial natriuretic peptide has been shown to protect the myocardium from the consequences of ischemia following a coronary occlusion and reperfusion [44]. Cardiac hypertrophy and fibrosis The NPR-A system has been shown to have direct anti-hypertrophic effects in the heart [45, 46]. A study on mice lacking the NPR-1 receptor showed cardiac hypertrophy and fibrosis which was disproportionate to the increase in blood pressure [47]. The study also suggested that cardiac ventricular expression of ANP was more closely related to hypertrophy and fibrosis than systemic blood pressure or plasma ANP concentration [47]. Another study exhibited an association between a functional deletion mutation of the NPRA gene and ventricular hypertrophy in a Japanese population [23]. Chagas Disease ANP and BNP have been shown to be elevated in several cardiac diseases exhibiting cardiac hypertrophy and heart failure. An elevation in the wall stress of the ventricles leads to an upregulation of the production of ANP and BNP in the ventricles, approaching levels in the atria where these peptides are normally produced [48]. In Chagas disease, there is evidence for ventricular upregulation and increased levels of ANP in both acute and chronic chagasic cardiomyopathy (CCC) [48]. However, the myocarditis itself does not appear to influence the production of ANP in ventricular myocytes [48]. In CCC, ANP expression is limited to the subendocardial region where wall stress is higher and is not found in the other inflammatory foci located away from the subendocardial region [48]. Thus, ANP levels are increased in the ventricular tissues and blood of patients with chagasic cardiomyopathy [48]. Therefore, ANP, along with BNP, can be used as molecule markers to identify patients with asymptomatic Chagas disease and predict clinical outcomes [49]. Pathological cardiac cachexia Cachexia is a common and serious complication of CHF, associated with poor prognosis independently of functional disease severity [50]. It is characterized by a generalized loss of lean tissue, fat tissue

46 A study on patients with isolated MR revealed that plasma natriuretic peptide levels increased according to the severity of the MR and were higher in symptomatic patients as compared to asymptomatic patients even when left ventricular ejection fraction (LVEF) remained normal [57]. In chronic MR, the levels of ANP and BNP and the BNP/ANP ratio has been shown to be a potential indicator of disease severity [58]. Reduction of the MR following treatment also exhibits a reduction in the levels of plasma ANP [59]. Asymptomatic and symptomatic left ventricular dysfunction Left ventricular dysfunction (LVD) is the most common precursor of CHF. It is characterized by a decrease in the LVEF. Recent studies have shown that the circulating levels of natriuretic peptides are increased in accordance with the degree of LVD [60, 61]. BNP has been shown to be better than ANP as a prognostic tool for assessing the severity of LVD as it demonstrates a greater correlation with LVEF than ANP [60, 61]. ANP as a cardiac biomarker The plasma concentrations of natriuretic peptides have been shown to be markedly increased in patients with cardiac disease. Studies have shown that natriuretic peptides improve discrimination and classification of heart failure and atrial fibrillation above and beyond conventional risk factors [62]. They can therefore be used in risk stratification and tailoring of therapy for patients with cardiovascular disease [63].

Role of atrial natriuretic peptide in cardiac pathophysiology

Role in fetal cardiac distress Fetal cardiac distress is associated with compromised heart function and hypoxia. The natriuretic peptides are common indicators of cardiac distress and their levels are therefore increased in these fetuses [70]. Studies conducted on ovine fetuses showed that there was a significant increase in natriuretic peptide levels and cGMP levels in fetal bypass [70]. Studies conducted on human fetuses have also showed that natriuretic peptide levels are elevated in fetuses exhibiting fetal distress [71, 72].

Therapeutic implications
Antihypertensive therapy ANP has strong potential to be used as an antihypertensive agent due to its multi-faceted effects on blood pressure homeostasis, fluidelectrolyte balance and cardiomyocyte hypertrophy [73]. As such, it is the only agent which decreases the mean arterial blood pressure by causing vasodilation and increases the GFR [73]. It also inhibits the sympathetic nervous system and the renin-angiotensin-aldosterone axis, which are implicated in the pathophysiology of hypertension [73]. Treatment of obesity and weight-loss Recent studies have demonstrated the role of ANP in lipid metabolism via stimulation of lipolysis and increased mobilization of lipids in adipocytes [29-31]. High levels of ANP have also been linked to low body weight, decreased calorie intake and increased catabolism [52]. This suggests that ANP might be used in the treatment of obesity.

ANP in the fetal model of cardiovascular pathophysiology
Physiological fluid balance ANP and BNP have been shown to be expressed in the myocardium from 8th embryonic day and are two of the first markers of heart formation [64]. They constitute a dual natriuretic peptide system that is functional by mid-gestation and capable of responding to volume stimuli and the regulating blood pressure, salt and water in the developing embryo [64, 65]. The fetus exhibits higher levels of plasma ANP than adults. Fetal ventricles also express higher levels of ANP and BNP than adult ventricles [64]. As the fetus matures, the production of ANP shifts from the ventricles to the atria. Cellular development in cardiomyocytes The high levels of ANP expressed in the developing fetus suggest a possible autocrine function of ANP in embryonic cardiac development [66]. A study on chick embryonic cardiomyocytes in vitro, showed that the cells treated with ANP exhibited enhanced development of the cardiomyocyte network as well as elevated RNA content. This suggests that ANP accelerates cardiomyocyte proliferation by enhancing entry of the developing cell into the S-phase thereby increasing DNA synthesis [67]. Role of ANP in immune and non-immune hydrops Hydrops fetalis is described as the abnormal accumulation of fluid in two or more fetal compartments. Studies conducted on ovine fetuses showed a three to four-fold increase in ANP during the production of fetal hydrops [68]. The rate of return to a normal level of ANP was paralleled by the clearance rate of fetal hydrops [68]. A study conducted on human fetuses exhibited similar results [69].

Conclusion
This mini-review sheds light on the role of ANP in cardiovascular pathophysiology. The profile of the effects of ANP on the cardiovascular system is multi-faceted, and goes beyond blood pressure regulation. The therapeutic implications of ANP, and its role as a cardiac biomarker are further testaments to its importance.
Competing interests: The authors declare that no competing interests exist. Received: 8 April 2013 Accepted: 16 July 2013 Published Online: 16 July 2013

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Open Access
Health insurance: Can it work in Pakistan?
Huda Naim1, Hassan Bin Ajmal1, Gulrayz Ahmed1, Muhammad Danish Saleem1

Opinion and Debate

Abstract
Health insurance is the financial protection against the healthcare costs arising from disease or accidental bodily injury. Social health insurance (SHI) is a type of health insurance that provides insurance for the population of a country and covers the costs of healthcare. The SHI model is still in its early stages in Pakistan. Hospitals and healthcare are now the responsibility of the provincial governments and modified SHI models have been implemented in some provinces, while others are still contemplating on its workings. However, SHI in Pakistan cannot work unless a national level strategy is implemented. (El Med J 1:2; 2013) Keywords: Health Insurance, Pakistan

Opinion and Debate
Health insurance is the financial protection against the healthcare costs arising from disease or accidental bodily injury. Such insurance usually covers all or part of the costs for treating the disease or injury. Insurance may be obtained on either an individual or a group basis [1]. Social health insurance (SHI), also referred as National health insurance or statutory, is a type of health insurance that provides insurance for the population of a country and covers the costs of healthcare. It is usually instituted as a program of healthcare enforced by law. Even with developed countries, the SHI system has been introduced only recently. France, Korea and Switzerland are a few examples to quote. Others such as the German government have introduced a somewhat limited SHI system, in which only certain classes of the society are insured by law. These include people with annual income less than US$60,000, pensioners, students, homeless, jobless, disabled and the poor. On the other hand in Japan, the healthcare system is a combination of public and private sectors, which is managed by the joint cooperation of the ministry of health and the ministry of work and labor. The state of Belgium is another example where a national fund for sickness and Invalidity is present. Health insurance by law is compulsory and adopted for all salaried workers [2]. Another example of the Social Health Insurance is in the United Kingdom where the healthcare system is provided by National Health Service (NHS), which is primarily funded through general taxation. The core objective of this system is to provide the healthcare facilities to all legal residents in England with almost all the services free (with the exception of charges for some prescriptions and optical and dental services) at the point of their use. The idea behind its creation is that good healthcare is the right of every individual and should be available to all, regardless of wealth and status. It is based on three principles, namely meeting the needs of everyone, being free to the point of delivery and being based on clinical need, rather than an ability to pay [3]. Pakistan is not entirely a welfare state like the United Kingdom, as free or minimal healthcare is available only in the few government

run hospitals. As economic reforms are underway more and more insurance firms are opening up. But their target population is a selected few who can afford the monthly or yearly premiums. This form of personal health insurance is found in capitalist states such as USA, where the government has a public plan coverage which includes Medicaid, State Children's Health Insurance Program, Medicare and other small public health coverage plans [4]. Personal health insurance in Pakistan is for the very few. Most of the beneficiaries are employees of multinational corporations, many of whom are not even paying their own premiums. Under these circumstances, the question that arises is that how can a common man, who cannot even afford the basic necessities of life, pay monthly or annual premiums for his health insurance. As such, it seems logical that a social healthcare system is the best option for the people in a country where the per capita income is $1,254 [5]. Unfortunately, SHI is not an easy option for the developing or third world countries. Attempts to implement it on a large scale have garnered limited success. For example, in Thailand, a low income card and 30 Baht Scheme has been introduced to provide free and equal healthcare to the citizens [2]. Similarly, a National health insurance, has been initiated in South Africa which supports the poor, low and middle income workers funded by taxes. The rich meanwhile avail the private sector [2]. In Iran, most of the population receives health insurance by the Social Security Organization, which provides insurance to the employees of the formal sector. On the other hand, the Medical Service Insurance Organization provides health insurance for government employees, students, and rural dwellers [6]. India, on the other hand, has a system similar to ours. Like in Pakistan, the rural areas over there also largely depend on government support. The majority of India’s health infrastructure is in the private sector and more than 70% of healthcare expenses are met by consumers; only a mere 20% of the total population is covered under health insurance schemes. The majority is covered under either government or employer programs. The regular commercial health insurance, prevalent in USA and other countries, has less than a 2% penetration, mostly provided by life insurance and non-life insurance companies [7].

1

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Gulrayz Ahmed Email: gulrayzahmed@gmail.com
http://www.mednifico.com/index.php/elmedj/article/view/28

50 Which model can work for Pakistan? Pakistan spends a meager 3.5% of its annual budget on public health, 0.7% of its GDP. National public expenditure on health is $4 per capita, while total expenditure on heath is $18 per capita. This reflects the high share of private healthcare spending, including households, which accounts for 75.6% of healthcare expenditure. Social health insurance covers only 5% of the population but represents about 40% of federal and provincial governments spending on health [2]. Most of the country's hospitals and healthcare centers are privately run which implies that they have a tendency to impose significant financial burden on the common man. Indeed with the rising cost of living and inflation more and more people flock to the government hospitals. Few as these may already be, they are incapable of handling the ever increasing patient load. This obviously compromises both the standard and timely provision of healthcare. So what lies as a solution for a country like Pakistan? Indeed one may see some commercial health insurance initiatives like those seen in India. Allianz®, EFU® and the Adamjee® are some forerunners. But many newer ones like AsiaCare®, Alfalah®, Cresent Star®, PICIC®, Saudi Pak®, Universal are joining the industry [8]. Many of the larger corporations provide free healthcare to their employs and their families either by direct contract with particular hospitals or via insurance companies. But this does not reflect the state of most of the country as the common man cannot afford to pay the insurance premiums. Indeed SHI seems the ideal option! The SHI model is still in its early stages in Pakistan. Hospitals and healthcare have now been placed under the responsibility of the provincial governments and modified SHI models have been implemented in some provinces, while others are still contemplating on its workings. However, SHI in Pakistan cannot work unless a national level strategy is implemented. Many international donors have shown interest in providing provincial and federal government assistance in this regard. With the help of World Bank, UK aid from the Department of International Development and Asian development Bank, the provincial governments of Punjab and Khyber Pakhtunkhwa are trying to introduce SHI in Pakistan [2]. Although SHI is just one component of social public strategy, if appropriately structured, it can eliminate many equity issues in healthcare provision across the country.

Health insurance: Can it work in Pakistan?

Jooma and Jaleel have suggested a modified SHI model for Pakistan, which would incorporate the already active Benazir Income Support scheme and provide essential healthcare advantages for the poor [9]. This pilot model can be implemented in order to review its benefits; however, it does not provide a long term solution primarily because it targets those households who do not have a bread earner, many of whom already benefit from the government's free hospitals. Our plea is not for the very poor and unemployed, many who do get the benefit of the government hospitals. Nor is our plea for the rich who can afford the expensive healthcare or if not that, can afford the health insurance premiums. Our plea is for the common man. What the government needs to do is develop a tax based social health insurance program similar to that prevalent in many third world countries like Iran and South Africa that would be beneficial to the lower and middle class earnings members as well. To conclude, with the cost of medical services rising more than ever before and newer and expensive treatment plans being introduced, it will soon become impossible for the working middle class to reach the benefits of healthcare unless timely measures are taken to improve the structure of health insurance in Pakistan.
Competing interests: The authors declare that no competing interests exist. Received: 3 March 2013 Accepted: 7 July 2013 Published Online: 7 July 2013

References
1. A Glossary of Terms for Community Health Care and Services for Older Persons [http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf] 2. Abrejo FG, Shaikh BT: Social health insurance: can we ever make a case for Pakistan? JPMA The Journal of the Pakistan Medical Association 2008, 58(5):267-270. 3. The NHS in England [http://www.nhs.uk/NHSEngland/thenhs/about/Pages/ overview.aspx] 4. National Health Interview Survey [http://www.cdc.gov/nchs/nhis.htm] 5. Per capita income rises marginally [http://beta.dawn.com/news/720636/percapita-income-rises-marginally] 6. Mehrdad R: Health system in Iran. JMAJ 2009, 52(1):69-73. 7. Thomas TK: Health insurance in India: need for managed care expertise. The American journal of managed care 2011, 17(2):e26-33. 8. The Insurance Association of Pakistan: Members [http://www.iap.net.pk/ Members.aspx] 9. Jooma R, Jalal S: Designing the first ever health insurance for the poor in Pakistan--a pilot project. JPMA The Journal of the Pakistan Medical Association 2012, 62(1):56-58.

Vol 1, No 2

Bota R, Ahmed M

51

Open Access
The pathophysiological profile of interleukin-6 and anti-interleukin-6 antibody
Rafaqat Bota1, Mushtaq Ahmed1

Essay

Abstract
Interleukin-6 is a multifunctional cytokine produced by variety of cells including tumor cells. It is produced by monocytes, macrophages, Bcells and T-cells. Interleukin-6 stimulates platelet production through thrombopoietin. Interleukin-6 in surplus amount is also produced by epithelial ovarian cancer cells. Hence, it is a useful prognostic factor for ovarian cancer, and is associated with disease stage and survival period. (El Med J 1:2; 2013) Keywords: Interleukin-6, Ovarian Cancer, Cytokine

Essay
Interleukin-6 is a multifunctional cytokine produced by variety of cells including tumor cells. It is also produced by monocytes, macrophages, B-cells and T-cells. Interleukin-6 stimulates platelet production through thrombopoietin (the primary regulator of proliferation and differentiation of platelet progenitors). Interleukin-6 in surplus amount is also produced by epithelial ovarian cancer cells [1, 2]. Hence, it is a useful prognostic factor for ovarian cancer, and is associated with disease stage and survival period [1, 2]. Mouse models have supported the idea of tumor derived interleukin6 induced hepatic thrombopoietin synthesis as a causal mechanism of thrombocytosis [3]. Anti-interleukin-6 antibody treatment significantly reduced tumor induced thrombocytosis and also improved therapeutic efficacy of paclitaxel [3]. With combined treatment of siltuximab and paclitaxel, almost 90% reduction of tumor growth has been observed [4]. Human studies have also shown similar results. A study published in New England Journal of Medicine revealed that 31% of the patients i.e. almost 1 in every 3 epithelial ovarian cancer had thrombocytosis at the time of diagnosis [4]. Six hundred nineteen patients with epithelial ovarian cancer were analyzed to determine the association between thrombocytosis and disease outcome. The levels of thrombopoietin and interleukin-6 were significantly elevated. The study has shown that thrombocytosis is significantly associated with advanced-stage disease, thromboembolic complications and reduced survival in patients with epithelial ovarian cancer. It is therefore concluded that paraneoplastic thrombocytosis is a contributor that exacerbates the disease process. The aforementioned study warrants

further considerations and shows a possibility of improved outcome with anti-interleukin-6 antibodies in epithelial ovarian cancer patients. Apart from stimulation of platelet production through thrombopoietin, interleukin-6 is also responsible for maturation and differentiation of B-cells and T-cells, and hence may have a role in autoimmune diseases. The study conducted by Liang et al. has found favorable effects for systemic lupus erythematosus on treatment with anti-interleukin-6 antibodies [3]. In this regard, further studies are required to assess the complete role of interleukin-6 and to evaluate beneficial effects of anti-interleukin-6 antibodies in other autoimmune diseases.
Competing interests: The authors declare that no competing interests exist. Received: 15 February 2013 Accepted: 15 February 2013 Published Online: 6 July 2013

References
1. Gastl G, Plante M: Bioactive interleukin-6 levels in serum and ascites as a prognostic factor in patients with epithelial ovarian cancer. Methods in molecular medicine 2001, 39:121-123. 2. Kaser A, Brandacher G, Steurer W, Kaser S, Offner FA, Zoller H, Theurl I, Widder W, Molnar C, Ludwiczek O et al: Interleukin-6 stimulates thrombopoiesis through thrombopoietin: role in inflammatory thrombocytosis. Blood 2001, 98(9):2720-2725. 3. Liang B, Gardner DB, Griswold DE, Bugelski PJ, Song XY: Anti-interleukin-6 monoclonal antibody inhibits autoimmune responses in a murine model of systemic lupus erythematosus. Immunology 2006, 119(3):296-305. 4. Stone RL, Nick AM, McNeish IA, Balkwill F, Han HD, Bottsford-Miller J, Rupairmoole R, Armaiz-Pena GN, Pecot CV, Coward J et al: Paraneoplastic thrombocytosis in ovarian cancer. The New England journal of medicine 2012, 366(7):610-618.

1

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Rafaqat Bota Email: rafaqatmartin@live.com
http://www.mednifico.com/index.php/elmedj/article/view/26

52

Childhood Pneumonia

Open Access
Childhood Pneumonia - A never ending, developing world concern
Shaikh Hamiz ul Fawwad1, Gulrayz Ahmed1, Syed Arsalan Ali1, Anum Saleem1

Essay

Abstract
Acute respiratory infections (ARI) are the leading cause of death among young children in developing countries. Every year, they affect an estimated 156 million children below the age of five worldwide, of which 151 million children are in the developing world. Pneumonia is responsible for about 19% of all deaths in children aged less than 5 years, of which more than 70% take place in sub-Saharan Africa and south-east Asia with majority of cases occurring in India, China and Pakistan. Causative agents are Streptococcus pneumoniae for community acquired pneumonia, chlamydia and mycoplasma for ages less than 5 years, Mycoplasma pneumoniae in school-going children, Chlamydia trachomatis in infants between two weeks and four months of age and influenza virus and RSV for pre-school age. (El Med J 1:2; 2013) Keywords: Acute Respiratory Infections, Developing Countries, Pneumonia, Integrated Management of Child Illness

Essay
Acute respiratory infections (ARI) are the leading cause of death among young children in developing countries. Every year, they affects an estimated 156 million children below the age of five worldwide, of which 151 million children are in the developing world [1]. Pneumonia is responsible for about 19% of all deaths in children aged less than 5 years, of which more than 70% take place in subSaharan Africa and Southeast Asia with majority of cases occurring in India, China and Pakistan [1]. Causative agents are Streptococcus pneumoniae for community acquired pneumonia, chlamydia and mycoplasma for ages less than 5 years, Mycoplasma pneumoniae in school-going children, Chlamydia trachomatis in infants between two weeks and four months of age and influenza virus and respiratory syncytial virus for pre-school age [2, 3]. The current standard for management of pneumonia worldwide, including developing world, is undertaken through Integrated Management of Child Illness (IMCI) but the coverage remains poor in most countries, and support from donors and international agencies other than WHO is sluggish [4]. High incidence of childhood pneumonia in developing countries is attributed to several risk factors such as lack of exclusive breastfeeding, malnutrition, indoor air pollution, low birth weight, crowding, lack of measles immunization, low paternal education and young maternal age [1, 5]. Kirkwood et al reproduced interventions and strategies from WHO's Program for the control of ARI, suggesting three different clusters of preventive strategies: immunization, case management and strategies based on the modification of risk factors, along with appropriate chemoprophylaxis [6]. The last cluster was further subdivided into four categories: improving nutrition, reducing environmental pollution, reducing transmission of pathogens, and improving childcare practices. A total of 28 potential intervention areas were then identified among the resulting six intervention groups [6].

Almost all of the risk factors are modifiable and can be intervened with minimal effort and cost. Emphasis should be placed on ‘prevention’ as the key. Role of general physicians and primary health care workers is particularly important in emphasizing the importance of breast feeding and educating the mother of risk factors that can easily be prevented such as poor nutrition and hygiene. Mulholland in his article urges researchers and public-health professionals for the need to address four key areas, namely environment, nutrition, case management and vaccines in order to control pneumonia [4]. Mass campaigns on general awareness, maintenance of proper hygiene, hand washing techniques, promotion of cleanliness should be organized. In addition, vaccines of the major causative agents should be provided based on available epidemiological data. These are some steps which need to be taken and can help fight this killer, which is becoming a major threat for the world in general and developing countries in particular.
Competing interests: The authors declare that no competing interests exist. Received: 24 February 2013 Accepted: 6 July 2013 Published Online: 7 July 2013

References
1. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H: Epidemiology and etiology of childhood pneumonia. Bulletin of the World Health Organization 2008, 86(5):408-416B. 2. McIntosh K: Community-acquired pneumonia in children. The New England journal of medicine 2002, 346(6):429-437. 3. Heiskanen-Kosma T, Korppi M, Jokinen C, Kurki S, Heiskanen L, Juvonen H, Kallinen S, Sten M, Tarkiainen A, Ronnberg PR et al: Etiology of childhood pneumonia: serologic results of a prospective, population-based study. The Pediatric infectious disease journal 1998, 17(11):986-991. 4. Mulholland K: Childhood pneumonia mortality--a permanent global emergency. Lancet 2007, 370(9583):285-289. 5. Victora CG, Fuchs SC, Flores JA, Fonseca W, Kirkwood B: Risk factors for pneumonia among children in a Brazilian metropolitan area. Pediatrics 1994, 93(6 Pt 1):977-985. 6. Kirkwood BR, Gove S, Rogers S, Lob-Levyt J, Arthur P, Campbell H: Potential interventions for the prevention of childhood pneumonia in developing countries: a systematic review. Bull World Health Organ 1995, 73(6):793-798.

1

Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan Correspondence: Gulrayz Ahmed Email: gulrayzahmed@gmail.com
Vol 1, No 2

Waqar D

53

Open Access
A case of typical hemolytic uremic syndrome requiring three months of hemodialysis
Danish Waqar1

Letter to Editor

Abstract
This is a case of typical hemolytic uremic syndrome with no complications. The patient was treated with hemodialysis for 3 months and 11 sessions of fresh frozen plasma infusion along with supportive therapy with anti-hypertensives. (El Med J 1:2; 2013) Keywords: Hemolytic Uremic Syndrome, Hemodialysis

Case Report
A 16 year old female patient presented with jaundice and bilateral pedal edema. Physical examination showed: Blood pressure: 150/85; pulse: 90 bpm; respiratory rate; 15/min. Auscultation and percussion were unremarkable, although the patient did complain of palpitations. She had moderate jaundice for 4 days and bilateral non-pitting pedal edema for 2 days. On further inquiry, the patient’s attendant reported decreased urine output since 5 days and mild bloody diarrhea since 4 days. Complete history and examination revealed that the patient was anemic and also had weakness, anorexia and abdominal tenderness. Lab investigations were ordered: BUN: 101; serum creatinine: 3.4; serum ALT: 33 u/l; serum AST: 23 u/l. Complete blood picture revealed anemia (hemoglobin: 7.3 mg/dL); MCV: 65; WBCs: 9100; Differential: (Lym: 30%; PMN’s: 60%; Bands: 5%); Platelets: 85000/L); bilirubin (total): 3.1. Blood smear showed some schistocytosis and microangiopathic hemolytic anemia. Serum haptoglobin level was ordered and found to be decreased to 9.1g/dL. Estimated GFR was about 18ml/min, suggesting acute renal failure. 24hr urine protein was 3.2 grams. There was no specific history of raw meat ingestion but the attendant said that they often ate food from street vendors. Intravascular hemolytic anemia, anuria and bloody diarrhea were suggestive of hemolytic uremic syndrome (HUS). ADAMTS13 levels were ordered due to similar presentation of thrombotic thrombocytopenic purpura and showed normal levels. CD55 and CD59 levels were also normal, thereby excluding PNH and TTP. The diagnosis of HUS was confirmed by finding E. coli o157:H7 on stool culture report. The patient was given fresh frozen plasma at about 15ml/kg per 24 hours, every 2 days. The patient was also given 2 units of packed RBCs for anemia. The FFP infusion continued for 1 month. The patient was also put on hemodialysis with 3 sessions given per week. IV fluids were given (mostly 0.9% NS) and furosemide IV given every other day. ACE inhibitor was given for blood pressure control. The patient’s labs on 9th admission day were: platelets: 130,000/L; bilirubin (total): 2.1; serum creatinine: 2.8; eGFR: 20ml/min; hemoglobin: 10.5 g/dL. The patient had an uncomplicated 3 weeks stay in hospital with the same treatment and labs on the day before discharge were: platelets: 110,000/L; bilirubin (total): 2.5; serum creatinine: 2.9; eGFR: 23ml/min. The patient’s urine output also improved. The patient was discharged on antihypertensives (captopril and amlodipine), and regular hospital follow-ups every 2 days for FFP infusion and hemodialysis. The FFP infusion was continued for 45 days (11
1

sessions, including inpatient infusions when admitted and hemodialysis for 2 months. After 1 year patient had started going to school. Urine output was near normal. Labs: platelets: 200,000/L; bilirubin (total): 0.8; serum creatinine: 0.9; 24hr urine protein: <157 mg. Blood pressure was under control as the patient was still on antihypertensive.

Discussion
The pathotypes of intestinal pathogenic Escherichia coli are classified as follows: Shiga toxin-producing Escherichia coli (STEC), enterohemorrhagic Escherichia coli (EHEC), enterotoxigenic Escherichia coli (ETEC), enteropathogenic Escherichia coli (EPEC), enteroinvasive Escherichia coli (EIEC), enteroaggregative Escherichia coli (EAEC), and diffusely adherent Escherichia coli (DAEC) [1]. STEC/EHEC strains can cause hemorrhagic colitis and HUS [1]. EHEC O157:H7 has since been documented as the cause of both large outbreaks and sporadic infections in the United States and around the world [1]. Our patient is a classic case of typical HUS. In suspected cases of HUS, labs are ordered for complete blood picture, renal function tests, liver function tests and other causes are excluded. Since TTP and PNH are also closely related, ADAMTS13 and CD55 and CD59 levels were also done for our patient. Although PNH has splenomegaly, acute renal failure is fairly uncommon; still the hyperbilirubinemia led to suspicion. There are many other hematological, infectious and inherited conditions that present with jaundice, but in our case, acute renal failure and bloody diarrhea made the diagnosis of HUS highly relevant.

Prognosis
It is commonly seen that patients of typical HUS regain near normal renal function within 3 months, with 1 year follow up of approximately normal renal function tests. An exception to this is atypical HUS, which takes longer time to regain lost renal function. The major prognostic factor with regard to the risk of future complications is the combination of low GFR and proteinuria, both being signs of impaired renal function and ongoing hyperfiltration injury. This combination occurs in less than 10% of patients, but increases to about 15% in those with more than 10 days of oliguria, and 40% if oliguria lasts for more than 15 days. Those with anuria of more than 5 days duration exhibit both low GFR and proteinuria almost 20% of the time. It rises to 33% in those with more than 10 days of anuria, and to 66% in those whose anuria persists for more than 15 days. Overall, this subset of patients (who have both proteinuria and low GFR) is

District Headquarter Hospital, Haripur, Pakistan Correspondence: Danish Waqar Email: danishwaqar@gmail.com
http://www.mednifico.com/index.php/elmedj/article/view/29

54 most likely heading toward end-stage renal disease because of ongoing hyperfiltration injury [2]. The presence of multi-organ dysfunctions and hospital stay are also major prognostic indicators that predict the long term outcome of the disease. This patient was on hemodialysis for 3 months and was off hemodialysis after that and improved a lot within the next year. To summarize, this patient took a longer time than most of the other patients to get off hemodialysis. Futhermore, owing to the presentation with protienuria and decreased GFR and the presence of microalbuminuria at 1 year followup, this patient can be put in high risk category for ESRD and a 5 year follow-up is mandatory.

A case of typical hemolytic uremic syndrome…

Competing interests: The authors declare that no competing interests exist. Received: 10 April 2013 Accepted: 9 July 2013 Published Online: 11 July 2013

References
1. Kaper JB, Nataro JP, Mobley HL: Pathogenic escherichia coli. Nature Reviews Microbiology 2004, 2(2):123-140. 2. About HUS [http://www.about-hus.com]

Vol 1, No 2

Mahajan S, Sahoo P

55

Open Access
Pelizaeus-Merzbacher disease - A rare, dreadful disease
Siddharth Mahajan1, Parama Sahoo1

Letter to Editor

Abstract
Pelizaeus-Merzbacher Disease is a rare X-linked disorder resulting in neural insult due to lack of myelin deposition. Clinically patients can present with head tilt/nodding, pendular nystagmus, tremors, psychomotor retardation and hypotonia. The disease is associated with mutation in the PLP gene. Here we present a case of with head tilt, abnormal eye movements and psychomotor retardation. (El Med J 1:2; 2013) Keywords: Pelizaeus-Merzbacher disease, Psychomotor retardation

Introduction
Pelizaeus-Merzbacher Disease (PMD) is a rare, X-linked recessive disease. The main cause of the disease is a mutation in the proteolipid protein 1 gene (PLP1) gene [1]. In 1958, this disease was reported by Tyler [2]. Although many mutations on PLP1 gene has been explained, but in PMD, PLP1 duplication is the major etiology [3].

to mutation in PLP1 gene [1]. Currently there are four type of PMD classified on the basis of genetic mutations and pathology. The classical PMD is X-linked [4]. Usually in this disease the brain stem evoked potential, whether auditory or somatosensory, are abnormal [5]. In our case report we have describe a child with PMD who presented with classical symptoms like head tilt, binocular nystagmus, hypertonicity and gross developmental delay. Although a rare disease, the possibility of the child presenting with the symptoms mentioned in our case report should be considered for PMD because early diagnoses can alter the prognosis of the disease.
Competing interests: The authors declare that no competing interests exist. Received: 10 May 2013 Accepted: 16 July 2013 Published Online: 16 July 2013

Case Report
The patient was a 14 months old boy, born of non-consanguineous parents. Regular antenatal checkups were done for the mother and she was on calcium, iron and folic acid tablets. Delivery was full term vaginal delivery. Apgar score was 9 at 5 minutes. Birth weight of the baby was 2.6 kilograms, head circumference was 35 cm and birth length was 52 cm. There were no postnatal complications. At birth, hypertonicity of the lower limbs was seen. Later, at 4 months of age, he developed binocular nystagmus. At 9 months of age, he developed head tilt. The child presented with increase spasticity of the lower limbs and head tilt along with gross developmental delay. Opthalmologic review was done which showed normal fundus and optic disc. Otologic study showed decreased hearing bilaterally and visual and brainstem evoked potential reflected abnormal study. T2weighted MRI scan showed poor myelination and dysmyelination. DNA study confirmed the diagnoses.

References
1. Hodes M, Pratt V, Dlouhy S: Genetics of Pelizaeus-Merzbacher disease. Developmental neuroscience 1993, 15(6):383-394. 2. Tyler HR: Pelizaeus-Merzbacher disease: A clinical study. Archives of Neurology and Psychiatry 1958, 80(2):162. 3. Ellis D, Malcolm S: Proteolipid protein gene dosage effect in Pelizaeus– Merzbacher disease. Nature genetics 1994, 6(4):333-334. 4. Begleiter ML, Harris DJ: Autosomal recessive form of connatal Pelizaeus‐ Merzbacher disease. American journal of medical genetics 1989, 33(3):311313. 5. Shy ME, Hobson G, Jain M, Boespflug‐Tanguy O, Garbern J, Sperle K, Li W, Gow A, Rodriguez D, Bertini E: Schwann cell expression of PLP1 but not DM20 is necessary to prevent neuropathy. Annals of neurology 2003, 53(3):354-365.

Discussion
PMD is a rare X-linked disorder. The main etiologic factor is attributed

1

Kasturba Medical College, Manipal, India Correspondence: Siddharth Mahajan Email: siddharth.mahajan13@gmail.com
http://www.mednifico.com/index.php/elmedj/article/view/24

Instructions to authors
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world. He is the first Pakistani Spinal surgeon who has performed total disc replacement in spine in Pakistan. Dr Salman is the director of educational activities at LNH. His team has organized over 15 workshops in which they have trained Neurosurgeons and others in various events. It includes hands on Cadaveric workshops, training sessions on models/ sawbones and live surgery of new minimally invasive cutting edge technology.My electives experience with Dr. Salman was perhaps the most amazing. He is an excellent teacher and possess great sense of humor. It was a privilege to undertake the task of taking his interview on behalf of Blogemia and know more from his life and experiences. It was a great session 30 minutes long conducted at his OPD Clinic in Liaquat National Hospital on Saturday, 15th June 2013 at 1:30pm. 1) From where and when did you graduate? I did my MBBS from Liaqat Medical College Hospital, Hyderabad in 1987. Gen surgery FRCS from Royal college of Surgeons of England, London in 1993. FRCS ( Neuro surgery) from Royal college of Surgeons of England , London 1998. 2) Were you active in the Extra-curricular activities during your student life? I was always active in extra-curricular activities. I was the Badminton Champion in Medical School. I played as the Captain for Sindh University. Was a member at Hyderabad Gymkhana. I was also a member of Quad-e-Azam Scouts. I was the Best Debator at my college, and the Chairman of Debating & Literary Society. 3) Tell us something about your friends. I had really good friends during Med School. We’ve apent a great time together and all of us are very well established today Mash’allah. One of them today is now working as a Collecting Customs in Karachi. Another one is an Orthopedic Surgeon in Ireland, UK. One is an ER Consultant in London and another one in a Finance Consultant in Vancouver, Canada.

4) Any past experience whenever recalled always makes you laugh? It was during my General Surgery fellowship when our Senior Surgeon mistakenly operated at the opposite side of the hernia in a neonate. It was funny how he convinced the attendants that he checked both sides just in case-and the patient’s family was infact quite happy about it! Dr Salman is the director of educational activities at LNH 5) What is your success story and the secret behind it? My parents are the ones behind my success. I have always been supported by my father who was a doctor himself. We have always been a well-off family Mashallah. My father’s colleagues were all well-reputed doctors. My elder brother is currently an orthopedic surgeon at Ireland, UK. I got an excellent opportunity to do electives for 6 months in USA, while I was a 4th year Medical student, as the College was closed due to law and order situation of the city that time. Hence this strong background contributes the most to my success today. I will always remain thankful to my parents. 6) Any experience that added purpose to your life or motivated you to be what you are today? My electives in USA during 4th year of Medical College completely changed my life. I did electives in Harvard & Baylor medical University (Texas) and these 6 months added the boost to my career. 7) Why Neurosurgery? Surgery has always been my passion. And it was during my fellowship that I came across a rotation in Neurosurgery. I had decided that I would opt for the very first interview call I would get for my Residency- and it was Neurosurgery! So here is where I began from. 8) How would you define research and what is the value of research in your professional life? Research is a mind-opening method of learning, I believe. I had written lots of

Best of Blogemia
Interview with Dr Salman Sharif Hira Burhan
http://blogemia.com/interview-with-drsalman-sharif-neurosurgeon/ A person who believes that smile heals all pains-Dr. Salman Sharif is an impressive inspirational personality to look up to. Trained from England, Ireland and United States in Neurosurgery and Spinal Surgery and specialized in Spinal and tumor surgery from UK and USA, he is the first Neurosurgeon in Pakistan to use modern state of the art image guided, computer assisted surgical device (Stealth station) to operate on brain tumors and complex spine procedures. He is the first Neurosurgeon in Pakistan to use this cutting edge technology. He also uses endoscopes for treating different types of Hydrocephalus and brain tumors. He has vast experience of spinal and brain surgery both within Pakistan and abroad. He is a keen researcher and has presented papers and has been guest speaker in various international meetings throughout the

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papers during my training. And it is since the past 10 years that I have resumed my passion for research. I believe that we have a very primitive method of data collection in our country and there has to be a lot of improvement in our research methodology. 9) Tell us about your best and worst research experience? My best experience was while we were conducting a research on Tethered Cord Syndrome for which we won the best prize in British Neurosurgeons Meeting. The worst experience was when we did a study on Depression among Neurosurgeons and we found out that Neurosurgeons were at a 60% risk of developing depression compared to an ordinary person! This was very disturbing to know for us. 10) When you joined the department, what was it like and how is it currently different? I joined this department in 1999 and it has changed completely since the time I arrived. I had aimed to make it the most modern Neurosurgery department and today we are working with the most sophisticated minimally invasive image-guided procedures for Brain & Spinal Surgery. We are working in collaboration with the Cleveland Clinic, World Spinal Column Society (WSCS) & Pakistan Society of Neurosurgeons (PSN). Recently I have been elected as the Vicepresident of WSCS and the Director of Middle East Spine Society. I am also the visiting Professor at the University Keele, Germany. We are currently doing a number of sophisticated and modern surgical procedures including:Pedicle screw fixation Vertebroplasty Dorsal Column Stimulator 1st artificial disc insertion in Pakistan has been conducted here at LNH 11) What major projects did you do and how do you plan to make the department flourish? We have initiated a Neurosurgery Nursing Training program at LNH that provides quality training and certificate courses.

Similar courses have been conducted at Lahore. Currently we are providing training to young Neurosurgeons through Cadaveric courses in Lahore & Hyderabad as well. I have attended many workshops in USA, UK, Turkey, Germany, UAE, India, Malaysia, Dhaka, Brazil, Indonesia, in order to learn new techniques and make the most of its implementation to provide modern treatment strategies at Liaquat National Hospital. 12) Something you did that you are proud of or feel satisfied with? Training of young Neurosurgeons and inspiring my students to become one. I have a keen interest in teaching and feel very satisfied when teaching students at college and those coming for electives. I feel proud to be a part of the Annual meetings conducted by WSCS, Asian Congress of Neurosurgeons and South Asian Society of Neurosurgeons. 13) Is it easy for you to balance your personal & professional life in this tough career of yours? Indeed it is very tough to balance the time with your family in such a busy and hectic schedule. However, I try my best to manage with it. My family is very supportive. I love to go jogging with my son every morning and play Table Tennis with him when I get time. I take my family out for trips whenever convenient. It feels great being with your family. 14) What do you like to do in your spare time? I swim, play golf, travel for leisure, work on computer, watch movies and read books like Dan Brown. 15) Any interest in travelling, poetry, music etc? I travel a lot and there are just very few countries left for me to see now. I like listening to music and poetry to a certain extent. 16) What is your favorite resort? The Amazon in Brazil is my favorite place and Turkey (Izmir) is another good place I

love to go. 17) How different is the current student life from the student life of your time? It is totally different today! The use of gadgets like smart phones and laptops, have transformed the way students learn today. I remember I was in my 1st year of residency when I got my 1st phone and I was in 3rd year of training when I got my 1st laptop, which was the size of a desktop computer of today! I believe students today have gone too advanced and the technology has taken over the role of teachers and universities. 18) What do you think should be done for improvement? I think there is no proper guidance today for the students. They should be more practical and teaching should not be book orientedparticularly for medical students. 19) What do you think is the scope of research among students? It is a great way to learn practically! 20) Is Neurosurgery a field for women? Of course it is! The technique of minimally invasive and robot guided surgeries in future require delicate hands. 21) Any message for today’s students? Students need to understand that this is a period of globalization so at this time, when you are reading this article and wasting your time someone at Delhi or Izmir or Texas or London is reading, doing a research and going ahead of you. This is your time to avail and do your best to serve humanity with ethics and best possible knowledge. I wish you all the very best in your near future.

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Exchange Program – A Worthwhile Experience Amreek Kataria
http://blogemia.com/exchange-program-aworthwhile-experience/ “For those who dare to dream, there is whole world to live”. I am one of those persons who believe in fulfilling their dreams of life through intellectual rigor and hard work. Though belonging to the small village, I never restricted myself to the close boundaries; instead I aspired to be independent and made my way to Roanoke Collegeas a Global U Grad Exchange student.The programis a part of the U.S department of State’s Bureau of Educational and Cultural Affairs and is administered by the United States Educational Foundation in Pakistan (USEFP) and in the United States by the International Research and Exchange Board (IREX). Roanoke College is one of the program’s 61 partner schools. Living away from home on the other side of the world, has impacted me in ways that will stick with me forever. This exchange program changed my life in every way. I have become more independent and confident in myself. I am now looking at things from a broader point of view. My world has been expanded and with it I have expanded as a person.I learned not to judge things by their first impression, which I used to do before this exchange program. Living in a different culture, meeting people from all around the world entrenched in me confidence to approach strangers and find it easy to form new friendship. Before this program I was limited with my own culture but now I love diversity. I want to explore the world, want to know about different cultures. How people celebrate their different festivals, their marriages. I also enjoyed Halloween and Thanksgiving when I was in United States of America. This exchange program also changed my stereotypes about Americans. They are literally nice and friendly. They love humanity. They will greet you if they do not know you. They love their pets. Once I asked from my host mother, why most of the American people have pets. She explained me very well “Can you live on the road without food

and shelter”. This explanation impressed me. Now I love pets and can make friendship with them easily. I also want to highlight the experience of USAID conference, in which I was selected as a Youth speaker in “The Release of USAID policy on youth in development”. Where I highlighted youth can offer insight, guidance, innovative thinking and solutions. Youth can contribute to economic growth, social stability;ensure healthier more educated and productive society. There was also a question answer session. I shared my experience of working as a Co – Founder of Guru Nanak Trust and alsonon-profitable organizations. It was a pleasure talking in front of a big audience and meeting people belonging to different organizations. Now I feel if you have courage you can do anything. I was surprised to see the Pakistani Flag on the door. As I entered they played Pakistan’s National Anthem for me. They served Gulab Jamun (a Pakistani Dessert). How would you feel having Pakistani desserts in America? We also danced on Pakistani folk song “Ho Jamalo”, they really liked it. My mission at Roanoke was twofold. One was to polish my academic skills and second is to represent the real Pakistan. I acted as a bridge to connect two nations. I tried my level best to share my culture and to quell stereotypes on Pakistan. My professor and my friends liked my cultural dress. I gave two presentations on Pakistan; my friends supported me a lot. Four girls dressed Pakistani Shalwar Kamiz and my roommate, Pierce Golden, also dressed Kurta. I gave Ajrak to my professor; she also came with that Ajrak. I decorated table with the cultural things, to feel like we are in Pakistan. I talked on Stereotypes and also discussed the beauty of Pakistan, cultural diversity, cultural heritage, food, weddings, and religion. I also emphasized on achievements by Pakistani People. I want to add few comments which I received after my presentation. “I honestly want to go to Pakistan even more.”

interested in visiting Pakistan before it, I am really going to try to make a trip over there within the next few years!!”

“Opened my eyes to the real Pakistan! Keep on representing the best of what Pakistan has to offer!”

“Before presentation I had same stereotypes as you mentioned in your presentation but now you have changedmy mind I will definitely visit Pakistan”.It feels sometimes tears in your eyes and smile on your face to hear good compliments about your country. I also made Pakistani Samosa and Sharbat, everyone loved it. In the last we all did dance on folk songs everyone relished Pakistani dance.

When I was in U.S,it was an election time. I volunteered at Mitt Romney’s Rally. Ricky Kresge entertained the audience. People were enthusiastic to see Mitt Romney. They also brought dozens of water bottles as a donation. I also got a chance to see Virginia senator George Allen. One of the interesting things which I found that there were also kids in the rally and parents were explaining everything to their kids. Mitt Romney gave very inspirational speech. I also got a chance to shake hands with him. I did not see a single strike during election time. On the other hand they engaged in constructive debates and let people decide that their policies will benefit them or not. I liked this accomplished style of election.

Clinical Observership: I did my clinical observership at Carilion Clinic. I shadowed two professors on different days in Internal Medicine andEmergency department. I found faculty very friendly. We saw many patients in outpatient clinic. I learned how to get proper history, proper consent before examination and to perform general as well as systemic examination. I was not allowed to touch the patient so I observed everything. Counseling was one of the most important parts in practice. I learned how to write notes on computer software. It was

“You did your country a great justice and I am happy to say that although I was already

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a nice experience to observe the things closely. It is valuable to note here that significant differences exist between U.S and Pakistani medical system. But no doubt we are continuously moving towards standardized system day by day.

should be a platform where every youth has equal rights. Girls should be encouraged to study. Youth should be involved as an active participant in the development of nation.

avoid them altogether; rather eating fruits with low to medium glycemic index in moderation is recommended, as the total amount of carbohydrates matters more for the blood sugar level than the source of carbohydrate. Now these questions arise: should diabetics keep fruit consumption to the minimum due to its sugar content or avoid them altogether? Do the benefits of fiber content, vitamins, minerals and other nutrients in fruits outweigh the detrimental effect of their sugar content on blood glucose level? Due to conflicting advices of health professionals and lack of research content on this matter, answers of these questions are still not clear. However, a new study in Nutrition Journal by Christensen et al should provide some guidance regarding this matter. It is the first randomized trial to address this issue in which 63 overweight men and women with newly diagnosed Type 2 diabetes were included in the study by the researchers. They were randomly divided into two groups. Each participant was provided with medical nutrition care but one of the groups was advised to take at least two pieces of fruit a day (high-fruit) and the other group was advised not to consume more than two pieces of fruit a day (lowfruit) for 12 months. Fruit intake was selfreported using 3-day fruit records and dietary recalls. The aim was to check how this altered their levels of glycosylated hemoglobin, which gives an indication of blood sugar level over time. The high-fruit group consumed about 320gm fruit each day, and the low-fruit group ended up consuming about 135gm fruit daily. After 12 months glycosylated hemoglobin level was decreased in both groups with no significant difference between the two groups. Body weight and waist circumference also reduced in both groups but high-fruit group members had slightly greater reduction. As it is the recommendation of standard medical nutrition therapy to restrict the fruit intake in newly diagnosed overweight patient of type 2 diabetes, it leads to limited fruit consumption. However, the above study showed no effect of fruits on levels of Hb A1C, weight loss or waist circumference. Taking in consideration the other many possible benefits of fruits the authors

When I returned to Pakistan, my task was to share my U.S experience and bring the change in society. I want to outline two activities which I did on my return.

In the last I am very thankful to IREX and United States Embassy of Pakistan for providing me a global opportunity to develop mutual understanding between two nations.

• I worked as a tutor at Lincoln Elementary School Raonoke as a volunteer. I found new ideas to teach Mathematics and Science to kids. With keeping those ideas in my mind we have started same procedures at school from where I did my primary level.

I want to conclude with the following quotation,

“You are today where your thoughts have brought you.

• I am a medical student and living in a hostel. Near to our residency there are many small cafeterias where children are working as waiter. We have started the study session for them so that they can learn English and other skills. Our idea is to educate them so that they can get a better job.

You will be tomorrow where your thoughts take you”.

Are fruits fruitful for diabetics? S M Waqar Jaffri
http://blogemia.com/are-fruits-fruitful-fordiabetic/ The sweet and soothing feeling you get after eating any fresh seasonal fruit is such a huge blessing that the Almighty has bestowed on us. However some people, despite having such a blessing, are unable to fully enjoy them. Diabetes Mellitus is a disorder of carbohydrate metabolism, in which patients are advised to restrict their sugar intake and avoid glucose rich foods. Currently, medical nutrition therapy is considered as vital treatment option to control blood glucose level, especially in type 2 diabetes. Most of recent guidelines emphasize on taking high fiber diet including fruits, due to their undisputed benefits on human health. Yet some health care providers strongly believe that fruit consumption has an adverse effect on blood glucose level and hence advise to limit the fruit intake. Nowadays it is a common myth that diabetics should not eat certain fruits that are too sweet. Some of them do have greater sugar level, but it does not mean diabetics should

Application procedure is quite simple. All the required information is available online. USEFP accepts application throughout the year. I would highly recommend you to apply for this program. This program will not only polish your academic skills but also develop your leadership skills. You will get a chance to meet people around the globe. I made a video, My life in U.S as a Global U Grad Student, in which I wrapped my experience.

“Goals are the fuel in the furnace of achievement”. The major challenge to today’s youth is that they belong to diverse societies. Many factors affect in the succession and development of youth such as economic status (opportunities are not equal for poor, middle class and rich people), gender, marital status, religion and ethnicity. To overcome that problem there

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wrote, “We recommend that fruit intake should not be restricted in Type 2 diabetic subjects.” The bottom line is that restricting fruit intake has not proven beneficial in type 2 diabetes, but still more research is required. Some fruits having low glycemic index have been proven beneficial in diabetics not only

due to their nutritive value but also their role in controlling blood sugar level. These fruits include jamuns, guavas, peaches, berries, apples, plums, pears, cherries, grape fruits etc. A few fruits having moderate to high glycemic index should be consumed in moderate amount by diabetics. These include bananas, dates, oranges, watermelons, mangoes, papayas, pineapples etc.

Liesbet Delport, a registered dietician and co-founder of the Glycemic Index Foundation of South Africa says, “There is no such thing as a ‘bad’ fruit. However, when you have diabetes, it is important to control your blood glucose levels at all times, which means that you also have to look at the glycemic index of foods – a measure of the effects of carbohydrate-rich foods such as fruit on blood sugar levels.”

We require avid bloggers and medical writers to lead our sister blog, Blogemia. We are looking for section heads, editors and contributors. Those hired will be responsible for submitting at least five blogs (>500 words) per month. Individuals working in any of the aforementioned capacities will receive a share of the advertisement revenue. To apply, send your CVs along with samples at: apply@mednifico.com

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We accept Original Articles, Review Articles, Case Reports, Opinions and Debates, Essays, Letters to the Editor. There are no paper submission charges. Submit your articles via the online system or send as an email to: submit@mednifico.com We require editors, programmers, layout designers and proofreaders for our editorial staff. We also require avid medical bloggers for our sister website, http://blogemia.com. We are also looking for journal representatives from different medical schools. To apply, send your CV to: apply@mednifico.com El Mednifico Journal, Address: C2 Block R, North Nazimabad, Karachi – 74700 – Pakistan. Email: editorial@mednifico.com. Phone: (92-334)2090696.