Lupine Publishers| Heat wave killings in Pakistan and possible strategies to prevent the future heat wave fatalities

Lupine Publishers | Journal of Health Research and Reviews

Abstract

There is near unanimous scientific consensus that greenhouse gas emissions generated by human activity will change Earth's climate. The recent (globally averaged) warming by 0.5°C is partly attributable to such anthropogenic emissions. Climate change will affect human health in many ways-most adversely. Heat waves are the most fatal type of weather situations and they happen irregularly in different countries. Heat waves are well-known in other countries but the people of Pakistan became familiar with it in 2010 when the extremely high temperature was recorded at Mohenjo-Daro, which was the hottest temperature ever recorded in Asia. After this incident heat waves again knocked the boundary of Pakistan in 2015 and at this time it caught attention because it resulted in a lot of deaths due to hyperthermia. Heat waves form when high pressure aloft become stronger and remains over a region for several days up to several weeks. Areas of high population having dense accommodation and poor people are at risk to the adverse effects of heat waves. Government should take steps to prevent deaths by investing in the electrical infrastructure. Besides this, public awareness is also important to minimize the loss.

Introduction

A long period of intensive hot weather along with high rate of humidity is referred to as a heat wave especially in oceanic climate countries. A definition based on Frich et al. [1,2] Heat Wave Duration Index is that a heat wave occurs when the daily maximum temperature of more than five consecutive days exceeds the average maximum temperature by 5°C (9°F), the normal period being 19611990. According to the definition given by Glossary of Meteorology, "heat wave is a period of abnormally and uncomfortably hot and usually humid weather" [3]. Heat wave refers to both regular weather variations and to very unusual heat spells that occur once in a century. Warmer climates with increased mean temperatures seems to become more intense, longer lasting, and more frequent in future [1,2]. Intense heat waves have caused disastrous crop failures, thousands of deaths from hyperthermia, and extensive power outages due to excessive use of air conditioning. A heat wave is considered extreme weather and a threat because heat and sunlight together may overheat the human body. Urban areas experience high temperatures than rural because of the "Heat Island" effect. Experts say that this recent heat wave of 2015 in Pakistan is because of the reason that South Arabian Sea and the Indian Ocean are in phase of convergence which is causing aggravation in temperature of the sea shores and adjoining areas.

History

Heat waves are the most fatal type of weather situations. The first case was reported in Eastern North America in 1896 and this heat wave killed 1500 people but it also happens at irregular intervals in different countries. According to the Agency for Health care Research and Quality, about 6,200 Americans are hospitalized each summer due to excessive heat, and those at highest risk are poor, uninsured or elderly [4]. In 2003, more than 70,000 Europeans died as a result of the European heat wave [5]. The European heat wave of 2006 was the second giant heat wave to harm the continent in four years, with temperatures rising to 40 °C (104 °F) in Paris; In Ireland, which has a moderate maritime climate, temperatures of over 32 °C (90 °F) were reported. Highest average July temperatures were recorded at many locations in Great Britain, Netherlands, Denmark, Sweden and Germany. The past year, 2014, has been ranked the warmest year on record, driven by the accumulation of heat-trapping greenhouse gases in the atmosphere. However, 2015 is not too far behind. Nine of the 10 hottest years on record have all occurred in the 21st century.

Extreme weather in Pakistan

The highest temperature ever recorded in Pakistan is 53.5 °C (128.3 °F) which was recorded in Mohenjo-daro, Sindh on 26 May, 2010. It was also the hottest reliably measured temperature ever recorded on the continent of Asia and the fourth highest temperature ever recorded on earth [6,7].

Record-breaking 2010 summer heat wave

The hottest temperature ever recorded in Asia and the fourth highest temperature ever recorded in the world was in Mohenjo- daro, Sindh at 53.5 °C (128.3 °F) on May 26, 2010. Twelve cities in Pakistan had temperatures above 50 °C (122 °F) during the severe heat wave of summer 2010, which lasted from May 22 to May 31, 2010 [8]. On May 27, temperatures higher than 45 °C (113 °F) harmed areas across Pakistan and at least 18 people died as a result [9]. Also, during the extreme heat wave season, 11 cities experienced their highest ever recorded temperatures of 50 °C (122 °F) or above, and five cities experienced temperatures of 53 °C (127 °F). 11 cities also saw extremes of more than 45 °C (113 °F) but below 50 °C (122 °F). The previous record-temperature for Pakistan and for Asia was on June 12, 1919 at 52.8 °C (127 °F) at Jacobabad [10, 11].

2015 summer heat wave and death toll in Pakistan

In Pakistan's Southern areas high temperatures were recorded . The temperature ranged from 49 °C (120 °F) in Larkana and Sibi to 45 °C (113 °F) in Karachi. In southern Punjab, 40 °C (104 °F) was recorded in Multan whereas several areas of the Balochistan province were also affected where temperature reached to 49 °C (120 °F) in Sibi and Turbat. In the Southern Pakistan, the death toll climbed to 1233 in 2015 because of the severe heat wave. Among them, 260 bodies were never identified. According to the officials, they were either homeless people who sleep rough on the streets or maybe drug addicts [12]. During this heat wave, around 65,000 people were treated in Karachi hospitals because of the heatstroke [13]. Elderly and poor were the worst affected groups. This heat wave was observed during the fasting month of Ramadhan which further worsen the situation along with power cuts.

Recorded temperatures

Extreme temperatures started to grip Pakistan's southern areas on 18 June 2015, and peaked on 20 June [14,15] (Table 1) By 24 June 2015, the temperature and death records began to decline; the maximum temperature in Karachi was 37 °C (98 °F), and officials reported 58 deaths compared to 300 the prior day [16] (Figure 1).
Table 1.

Figure 1.

How they occur

Heat waves form when high pressure aloft (from 10,000-25,000 feet (3,000-7,600 metres) become stronger and remains over a region for several days up to several weeks. This is common in summer (in both Northern and Southern Hemispheres) as out flux �follows the sun�. The high pressure area is on the equator side of the out flux, in the middle layers of the atmosphere. Summertime weather patterns are generally slower to change than in winter due to which this mid-level high pressure also moves slowly. The air sinks toward the surface under high pressure. This sinking air acts as a dome covering the atmosphere. This cap helps to trap heat instead of allowing it to lift. There is little or no convection without the lift and therefore little or no convective clouds with minimum chances for rain. So, the end product is a constant build-up of heat at the surface that people experience as a heat wave [17].

Health risks

Our body produces heat, mostly during physical activities. Hot air, sun rays, and hot surfaces also heat up our body. This heat can be lost by contact with cool air and by sweat production, which cools our body as it evaporates. Weather situations play a huge role in how our body maintains its temperature. For example, if it's windy, sweat evaporates faster, which helps to cool.com. But high humidity slows down this process, aiding to increased body temperature. Heat illnesses can affect.com immediately, and can lead to long-lasting health problems and even death. They are caused by being over-exposed to intense heat especially if we are doing too much for our age and physical condition. Heat illnesses include: heat edema (swelling of hands, feet, and ankles), heat rash, heat cramps (muscle cramps), heat fainting, heat exhaustion and heat stroke. Extreme heat can keep everyone at risk from heat illnesses. Health older adults, infants and young children, people with chronic illnesses (like breathing problems, mental illness, and heart problems), human beings who work in the heat, people who exercise in the heat, homeless people and people with low-income.

Security tips

There are number of things that people can do to help themselves from heat wave. These include. These include wearing damp clothes which will help lower the body's temperature, sticking one's hands in cold water, placing fans next to windows as this will draw air from outside, which should be cooler, wearing loose clothes, having a lukewarm shower rather than a cold one and fanning the face rather than other parts of the body [12]. Look for side effects of warmth illness, which include: dizziness or swooning, nausea or heaving, headache, rapid breathing and pulse, extreme thirst (dry mouth or sticky salivation), decreased pee with uncommonly dull yellow pee, changes of conduct in kids (like drowsiness or fits). When individual has any of these side effects during amazing warmth, move him to a cool place and beverage fluids immediately.
Water is best. While sitting tight for help - cool the individual immediately by moving them to a cool spot, apply ice-cold water to major areas of their skin or garments, fan the individual however much as could sensibly be expected. Drink a lot of cool fluids (mainly water).Never leave individuals or pets inside a stopped vehicle or in direct daylight. When the outside air temperature is 23^oC/73^aF, the temperature inside a vehicle can be strikingly dangerous - more than 50^oC/122^oF.

Why so many people died in Karachi's heat wave

Karachi's heat wave resulted in high number of deaths which was the cumulative effect of Ramadan when people fast from dawn to dusk, prolonged electricity shortages, pollution, chronic water shortages and climatic change [12]. A person who survived with heat wave said that "It was difficult to breathe, as if the air had no oxygen". Majority of the people, including the authorities were not aware of the deadly impact of heat wave and no warnings were issued. The provincial government seemed completely unresponsive to this unfolding tragedy. Experts say that this heat wave is the result of phenomenon called "time mover". Scientists warned that heat wave will become more frequent and intense due to the climatic change but government is yet to recognise this impending threat. Many of these deaths could have been avoided if the people were provided with clean drinking water in access and had given early warnings in relation to heat wave [18].

How to prevent future heat wave fatalities in Pakistan

People of Pakistan are not strange to high temperatures with sizzling hot and humid weather in summer but from the recent killings it is proved that the local government failed to prepare for and respond to the heat waves. Something must be done to overcome this deadly threat which is increasing day by day. Heat Health action plan must be established to raise the awareness of health risks and to train healthcare workers so that they can recognise the signs of heat stress. A coordinated action is needed to prepare for the rising threat and a forecast system needs to be developed that can alert the administration to impending heat waves several days out [18]. Along with that, excessive trees are planted and energy from other key sources must be availed to overcome energy crisis.

Conclusion

Heat wave resulted in many killings in Pakistan due to the incorrect procedures in place and because of the lack of planning in government and social sector about how to cope with situations like this. During such situations, blackouts are common because of the energy crisis which put hospital patients at risk. We should look for the efficient strategies to counter associated loss. Public must be educated about potential heat related illnesses and preventive measures, early warning systems must be initiated, medical staff should be trained and adaptive measures are promoted

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Neurosarcoidosis: A Review of the State of Art-Lupine Publishers

Lupine Publishers | Journal of Health Research and Reviews

 

Abstract
 

Neurosarcoidosis is a rare disease, difficult to diagnose. A correct diagnostic approach should include a multidisciplinary assessment involving physicians, radiologists and pathologists. Corticosteroids are the first-line treatment for neurosarcoidosis, followed by steroid-sparing immunosuppressants.
Keywords: Sarcoidosis; Neurosarcoidosis; Central Nervous System Diseases; Peripheral Nervous System Diseases

Introduction

Sarcoidosis is a chronic disease with a highest annual incidence among African-American females (39.1/100,000) and males (29.8/100,000), followed by Caucasian females (12.1/100,000) [1]. Although sarcoidosis continues to be considered as an idiopathic disease, there is an increasing evidence of a genetic predisposition that associated with several environmental factors that act as trigger agents (e.g. mycobacteria, viruses, neoplasms and inorganic compounds as aluminum) contributes to the development of the disease [2]. Lungs and intrathoracic lymph nodes are the most frequently affected sites, but sarcoidosis can also involve the heart, skin, joints, gastrointestinal tract and nervous system.

Neurosarcoidosis

The involvement of the central and peripheral nervous system (neurosarcoidosis) is rare, clinically happening in about 5-10% of patients with sarcoidosis, with an average age of onset around 33-41 years [1]. Because of the rarity of this entity and the nonspecificity of its clinical and radiological findings, there is surely a high percentage of poorly diagnosed cases, mainly in an initial approach, as the neurological involvement can be found in up to 25% of autopsies from patients with sarcoidosis [1,2]. Non-specific symptoms such as fatigue, headache, cognitive dysfunction and mood disorders are frequent in cerebral neurosarcoidosis, but the clinical picture is usually dominated by cranial neuropathy or aseptic basilar meningitis. The damage of the optic nerve, the most frequently affected followed by the facial nerve, is associated with a poor prognosis in terms of visual recovery [3]. Spinal neurosarcoidosis can be divided into intramedullary and extramedullary involvement (leptomeningeal, extradural, vertebral and disc involvement); paresthesia and weakness of the lower extremities are the main symptoms, although it often presents as symmetric sensory motor polyneuropathy. Rarely, cases of sudden paraplegia can occur, along with bowel and bladder dysfunction [3].

Diagnosis

The Zajicek criteria are the mostly adopted classification system for neurosarcoidosis established in 1999 and later revised. The other set of criteria belong to WASOG (World Association of Sarcoidosis and Other Granulomatous Disorders), updated in 2014. The specificity and sensitivity of these two options are unknown [4]. A definite diagnosis of neurosarcoidosis can only be established with a positive biopsy of the affected nervous system, frequently considered impossible or too invasive; for this reason, the biopsy is usually performed outside the central nervous system, in a peripheral nerve or another affected and more accessible organ (as neurosarcoidosis frequently coexists with other organ involvement). None of the serum biomarkers used nowadays have been accepted as the one that stablishes the diagnosis, including the angiotensin converting enzyme (ACE) or the serum soluble activity of the interleukin-2 receptor (sIL2 receptor) [1].
Levels of ACE in cerebrospinal fluid (CSF) have a low sensitivity (between 24-55%), but may raise the suspicion of neurosarcoidosis due to its high specificity (around 94%). It seems that there is no correlation between serum and CSF levels of ACE and serum levels do not correlate with the degree of clinical activity [5]. Image findings should not be considered alone for the diagnosis of neurosarcoidosis, but always included in an appropriate diagnostic algorithm. Magnetic resonance imaging (MRI) is the preferred imaging technique because it provides the best definition for brain and spinal cord disease [3,4]. Meningeal involvement can appear as nodular or diffuse enhancement on contrast-enhanced T1- weighted images, mainly in the basilar meninges, as opposed to intraparenchymal lesions that manifest as multiple small, nonenhancing periventricular or subcortical white matter lesions, with high signal on T2-weighted images [3]. Fluorodeoxyglucose positron emission tomography (FDG-PET) can reveal areas of hypermetabolism that correspond to active lesions in asymptomatic sites, which can be used to identify suitable sites to do a biopsy, although there is a lack of evidence regarding the use of FDG-PET and its usefulness in neurosarcoidosis [4]. Histopathologically, neurosarcoidosis is characterized by the presence of noncaseating epithelioid granulomas, the same lesions as those found elsewhere in the body in systemic disease. These granulomas although not specific for sarcoidosis, are valuable diagnostic clues [1]. The differential diagnosis includes: tuberculosis, especially in endemic areas, other infections like histoplasmosis, aspergillosis and cryptococcosis, but also granulomatosis with polyangiitis [6].

Treatment

There are no international guidelines to treat neurosarcoidosis and randomized clinical trials are lacking to make treatment recommendations. Taking this into consideration, there is a general consensus that corticosteroids should be the first line of treatment, as the majority of patients improve with only glucocorticoids [1,3,7]. If the symptoms are severe, with involvement of the central nervous system, a short course of intravenous steroids is usually given, up to 1g of methylprednisolone a day for 3-5 days. Subsequently, or if the clinical symptoms are less severe, oral steroids can be administered (e.g. prednisone 40-80mg, around 1mg/kg/day), with gradually descending pattern until the lowest effective or maintenance dose (around 10mg/day). Relapse often occurs after the dose of glucocorticoids is tapered down; if the required maintenance dose is more than 10 mg a day, or if clinical response is insufficient, it is recommended to add a steroid-sparing immunomodulatory agent. The evidence is in favor of methotrexate (between 10-25mg once a week), but other immunosuppressant drugs can be considered, such as azathioprine (at 2mg/kg/day, maximum 200mg/day) [1,3,7]. In severe resistant or refractory cases, cyclophosphamide is classically used (500-1000mg iv every 2-4 weeks, or at a dose of 0.5g/m2 of body surface area every 4 weeks).
Anti- TNF-alpha agents are becoming strongly recommended because of the increasing evidence of rapid reversal of clinical and radiologic features with these agents, especially infliximab (intravenously at a dose of 3-5mg/kg at weeks 0,2 and 6, with intervals of 4-6 weeks thereafter); some groups are already considering this treatment option before cyclophosphamide [3,7]. Patients treated with long-term infliximab could develop anti-infliximab antibodies that will lead to treatment failure. To avoid this, concomitant methotrexate is recommended, as an immunomodulatory agent. When to stop the treatment remains controversial [7]. Surgery is generally limited to the diagnostic biopsy rather than to the therapeutic use. Cranial mass lesions could benefit from radiation therapy, although this is not recommended as standard treatment [3].

Prognosis

There is no cure, but optimal immunosuppressive therapy can achieve clinical remission in approximately two thirds of cases, along with variable improvement in imaging findings. Despite the use of new therapies, close to one third of patients remain stable, deteriorate or die [3,8].

Conclusion

The optimal diagnostic approach to neurosarcoidosis should include a multidisciplinary team with physicians, radiologists and pathologists. Corticosteroids are the first-line of treatment, followed by steroid-sparing immunomodulatory agents. There is increasingly more evidence considering anti-TNF-alpha agents as the therapeutic of choice for severe resistant or refractory cases. When clinical deterioration progresses despite intensive immunosuppression treatment, an alternative diagnosis should always be ruled out. New therapeutic approaches are expected in the upcoming years.

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