ISSN(Print) 2076-2860 ISSN(Online) 2958-5945 Email: Editorial@jaimc.org Phone: +924299231453 PMDC & UHS (IP-0043)
EDITORIAL
ARE OUR HEALTHCARE PRACTITIONERS PHARMACOVIGILANT: SHOULD THIS BE AN ISSUE OF CONCERN?
Shahid Mahmood, Maria Arshad
https://doi.org/10.59058/jaimc.v21i1.101
ORIGINAL ARTICLES
OUTCOME OF DELAYED HYSTERECTOMY FOR PLACENTA PERCRETA IN A TERTIARY CARE CENTER OF A THIRD WORLD COUNTRY— A DESCRIPTIVE STUDY
Alia Zainab Asad, Humna Sajid Sial, Hina Masood, Filza Mukhtar, Fatima Mateen, Mobeen Riaz, Noreen Akmal
https://doi.org/10.59058/jaimc.v21i1.90
ABSTRACT
Objective: To analyze the amount of hemorrhage, damage to the surrounding structures, need for transfusions, PPH, sepsis and mortalities arising as a result of delayed hysterectomies for Placenta Percreta. Methods: It was a descriptive study conducted at OBGY unit 3, Sir Ganga Ram Hospital from March 2021 to March 2022. Data was taken from specially maintained registers for placenta accreta spectrum. Patients undergoing delayed hysterectomies for inoperable placenta percretas were selected and their data regarding the mentioned outcome measures was collected and analyzed in SPSS. Results: Thirteen (13) patients underwent delayed hysterectomy in one year. More than half of the patients had four litres or less blood loss. They showed better response to haemorrhage. No relationship of amount of bleeding with interval between the surgeries, previous surgeries or parity was noted. No ureterovesical damage. No sepsis. PPH was noted in 15% of patients and mild spotting in 15%.One death of a morbidly obese patient was observed. No death could be attributed to retention of placenta. Conclusion: Encouraging results were seen where patient survival was concerned. Excellent results were noted where collateral damage to bladder and ureters was concerned. Minimum complications were noted, making this a viable option for patients with placenta Percreta, the most serious placental condition within the placenta accreta spectrum.
RISK OF NON-HEALING IN ISCHEMIC VERSUS NEUROPATHIC DIABETIC FOOT ULCERS IN RELATION TO GRADE, STAGE OF INFECTION AND TREATMENT PROTOCOL: A FOLLOW-UP STUDY
Hafiza Ammarah Sadiq, Mehwish Iftikhar, Rajia Liaqat, Amna Rizvi, Azhar Hussain, Muhammad Ijaz Bhatti, Ahmed Zafar Khan, Aysha Zafar, Fatima Javed
https://doi.org/10.59058/jaimc.v21i1.121
ABSTRACT
Background & Objectives: Diabetic foot ulcer (DFU) is a potentially crippling consequence of diabetic foot disease. Aim of this study was to determine the risk of non-healing in ischemic as compared to neuropathic diabetic foot ulcers in relation to its grade and stage of infection. Methods: This prospective non-interventional study was conducted from July 2019 to February 2020 in Diabetes Management Center, Services Hospital Lahore Pakistan. Patients presenting with DFU were assessed for neurological and vascular status in the lower limbs. Ulcer grading was determined by Wagner's and Texas classification. Patients were followed up to 2-6 months for healing status of the diabetic foot ulcer. Results: Of 132 patients, 97 (73%) patients presented with neuropathic ulcer and 35 (27%) were having ischemic ulcers. Most participants were aged between 40-59 years. Based on Wagner's ulcer classification, it was observed that patient with score 2 had three times more likely to have their ulcer healed compared to those with score 1 and 3 [OR =3.09(95% CI:0.62-15.38, P=0.17)]. Kaplan-Meier survival curves showed that healing pattern among ischemic ulcer is considerably better compared to neuropathic foot ulcers. The evidence of equal survival hypothesis using Log-rank (Mantel Cox) test was statistically significant (p<0.001). No statistically significant difference in healing pattern through time was found across Wagner's scoring categories. Conclusion: Peripheral neuropathy was the commonest pathology underlying DFU presenting at our tertiary level diabetes clinic. Early detection of neuropathy and timely foot care may help prevent ulceration with its often-grave consequences.
METABOLIC SYNDROME IN PATIENTS OF CHRONIC KIDNEY DISEASE PRESENTING TO THE NEPHROLOGY DEPARTMENT OF A TERTIARY CARE HOSPITAL
Muhammad Asad Saeed, Mehwish Akhtar, Muhammad Abdullah Munir, Kashif Ayub, Tamoor Nazir, Maria Arshad, Hira Samad
https://doi.org/10.59058/jaimc.v21i1.102
ABSTRACT
Background & Objective: The prevalence of metabolic syndrome (MetS) is on rise and is proven to be a known factor for cardiovascular diseases. However, its association with chronic kidney disease is also emerging which can accentuate the risk of cardiovascular events in patients of CKD. Therefore, this study was conducted to determine the frequency of metabolic syndrome and its related factors among patients with chronic kidney disease presenting to the Nephrology outdoor. Methods: It was a cross sectional study conducted at Nephrology department Jinnah hospital Lahore. About 110 patients of CKD diagnosed for atleast 6 months, aged 18-60 and fulfilling the selection criteria were enrolled after an informed consent by non-probability consecutive sampling. Measurement of blood pressure and central obesity was done as per standard protocol and all the information was recorded in proforma. A 5 ml of blood sample was taken for triglyceride, HDL, and fasting blood sugar levels after ensuring overnight fasting. Frequency percentages were calculated for qualitative variables by using SPSS26. Chi-square test was applied to check statistical significance between metabolic syndrome and effect modifiers. Results: The Mean age of patients was 42.46 + 5.580 with about 63(57%) being male. Majority had CKD stage-V 64(58%), and had the disease for more than 5 years i.e. 75(68%). The frequency of MetS was 39(35%) with that of high blood pressure 68(62%) being the most common among all components, followed by high fasting plasma glucose levels 52(47%), high triglyceride levels 35(32%), high HDL levels 32(29%) and central obesity 30(27%). A statistically insignificant relationship of MetS was seen on stratification for age, gender, duration, and stage of CKD. Conclusion: It can be concluded that a considerable frequency of MetS 35% is present among patients with CKD. Thus, there is a dire need to screen all the patients with CKD for the presence of MetS as an essential component of their routine follow up. This will help in its early diagnosis and management which may halt the disease progression and decrease the morbidity and mortality associated with this lethal but manageable double burden of disease.
MODIFIED CHEVRON OSTEOTOMY FOR TREATMENT OF HALLUX VALGUS
Tanveer Haider, Muhammad Zafar Iqbal Shahid, Muhammad Khalid, Muhammad Siddique Hamid, Muhammad Khalid Syed, Asim Islam
https://doi.org/10.59058/jaimc.v21i1.93
ABSTRACT
Background & Objective: Hallux valgus is the most common forefoot deformity in adults, especially in females. Almost 150 different procedures have been described for the treatment of Hallux valgus deformity. Modified distal metatarsal Chevron osteotomy with distal soft tissue release is one of the most effective procedures for the correction of mild to moderate Hallux valgus deformity. Methods: This is a prospective observational study conducted at Department of Orthopedic Surgery Services hospital Lahore from Jan 2018 to Jan 2019 after taking permission from the hospital ethical review board. A total number of 20 patients of age between 25-65 years were included in the study. Informed written consent was obtained from each patient. Each patient underwent X- rays in dorsoplantar and lateral views in weight-bearing position including axial sesamoid view of the foot. Hallux valgus angle (HV), inter- metatarsal angle (IMA) were measured on x rays while clinically each patient was assessed for American orthopedic foot and ankle society score (AOFAS) pre-operatively. In all these patients, we performed the Modified chevron osteotomy with lateral soft tissue release and medial eminence excision with capsular repair. Post-operative follow-up was done at two weeks, six weeks, 3 months and at one year for the radiological assessment of HV angle and IMA along with AOFAS score on clinical examination. Results: Total no of patients enrolled in our study were 20 with 16 females and 4 males. Four patients had mild Hallux valgus while 16 patient had moderate Hallux valgus. Pre-operative mean AOFAS score was 56.50 ± 3.54. Six patients had B/L Hallux valgus deformity. Thus a total no. of 23 feet in 20 patient underwent Modified Chevron osteotomy with distal soft tissue release. Before surgery the mean HV angle was 31.52°±6.44° while mean IMA was 18°±1.10°. The AOFOS score improve from 56.50±3.54 pre-operatively to 85.95±6.15 after 06 weeks post-operatively. It further improved to 94±1.25 after 01 year at the final follow up. The mean HV angle was improved from 31.52°±6.44° pre-operatively to 6.4°±1° after 06 weeks and 6.42°±1° after 01 year post operatively. The mean IMA improved from 18±1.10 pre-operatively to 5.4±1.30 after 06 weeks post- operatively and 5.6°±1.1° at the end of 01 year. The osteotomy union time was 10-16 weeks after the surgery. There was no recurrence of the deformity, Infection, stiffness of the joint and avascular necrosis of metatarsal head noted post-operatively at the end of one year. The mean first metatarsal shortening was 3.6±1.2mm at the final follow up. The patient satisfaction was also good (90.5%). Conclusion: Modified chevron osteotomy with distal soft tissue release is a good procedure for correction of mild to moderate Hallux valgus. It allows a significant lateral displacement of distal fragment (4.5mm). This osteotomy improves the foot biomechanics, has got durable functional and cosmetic result.
OUT OF POCKET AND HEALTH FACILITY CHARGES AMONG PATIENTS UNDERGOING DIALYSIS AT SERVICES HOSPITAL, LAHORE
Muhammad Tauseef Jawaid, Muhammad Hashir Javed, Areeja Fatima, Muhammad Shahid Iqbal
https://doi.org/10.59058/jaimc.v21i1.97
ABSTRACT
Objective:- Dialysis is the process of removing waste products and excess fluid from the body. Dialysis allows the patient with kidney failure a chance to live a productive life. However, the out-of-pocket expenditure on this essential procedure can result in financial burden on these patients. The purpose of this study was to assess out of pocket expenditures and health facility charges among patients undergoing dialysis at Services Hospital, Lahore. Methods: It was a descriptive cross-sectional study conducted in the Dialysis unit of Services Hospital. About 130 patients undergoing maintenance hemodialysis were included in the study after an informed consent. Data were collected using a pretested questionnaire regarding all the study variables and was entered in SPSS for analysis to determine the out-of-pocket expenses in these patients. Result: Mean out of pocket expenditure (both medical and non-medical) was Rs.4950/- week while mean out of pocket charges on lab investigation were Rs.10300/- rupees during one year of dialysis. Mean monthly transport charges were Rs.1500, wheelchair charges were 150, expenditures on medicine were 2100 while charges of OPD and other treatment cost was Rs.1200. Study shows that 69.2% of the patients who had irregular treatment were suffering from co-morbidity while only 8.4% had no issue other than renal disease. There were 33 patients who reported irregularity in treatment. The reason for this irregularity was due to out- of-pocket expenditures, while 9.09% was due to other reason. Conclusion: Our research concluded that although the health facilities provided by the dialysis unit of Services hospital to the patients is free of cost, still a considerable proportion of money is being spent in form of medical and non-medical expenses which are not being covered by the government facilities. Strategic measures should be taken to decrease these expenses as well as to relieve the financial burden of these patients.
FETOMATERNAL OUT COME IN PLACENTA ACCRETA SPECTRUM (PAS)IN A TERTIARY CARE TEACHING HOSPITAL
Naila Yasmeen, Shahbaz Ahmad, Zohra Khanum, Fatima Khanum, Sania Khan
https://doi.org/10.59058/jaimc.v21i1.88
ABSTRACT
Objective: To determine the fetomaternal outcomes in PAS-Placenta Accreta Spectrum. Methods: This was an observational descriptive study conducted at Gynae unit 2, of FJMU/, Sir Ganga Ram hospital Lahore. Fifty patients of placenta accreta spectrum were included over one year study period. All booked and un-booked patients who had history of antepartum haemorrhage with or without per vaginal bleeding who were diagnosed of having PAS were included in study. Results: Fifty cases of placenta accreta spectrum (PAS) were studied over one year period. 35 (70%) patients with placenta Accreta Spectrum (PAS) were un-booked. 15 (30%) were booked. In 25 (50%) of patients age group ranged between twenty six to thirty years while the gestational age ranged between 32-36 weeks. In 35 (70%) of patients having type four major degree placenta previa while type three major degree Placenta previa was noted 10 (20%) of the cases .Regarding number of caesarean sections forty five (90%) had more than one caesarean section while only five (10%) had previous one caesarean section. Conclusion: Placenta Accreta spectrum (PAS) is associated with life threatening haemorrhage along with associated high feto-maternal mortality and morbidity. Early diagnosis by Doppler ultrasound and multidisciplinary is necessary to improve feto maternal outcome.
OUTCOMES IN PATIENTS WITH PROXIMAL HUMERUS FRACTURES UNDERGOING OPEN REDUCTION AND INTERNAL FIXATION WITH PROXIMAL HUMERUS LOCKING PLATE
Muhammad Zafar Iqbal Shahid, Sohaib Inaam Ullah, Muhammad Khalid, Naveed Ali Shair, Tahir Mahmood, Muhammad Iqbal
https://doi.org/10.59058/jaimc.v21i1.92
ABSTRACT
Background & Objective: Despite of conservative management for proximal humeral fractures, open reduction and internal fixation with proximal humeral locking plate has become the most frequent treatment for these fractures especially in elderly and osteoporotic population. Alot of complications are associated with proximal humerus internal locking system (PHILOS) plate including intra articular screw penetration, screw cut out, varus malunion, loss of reduction, nonunion and infections. Efforts have been made to improve the locking plate fixation technique and strengthen the fixation more resilient to head collapse, screws cut out, screw penetration and loss of fracture reduction. Methods: It was an observational study conducted in the Department of orthopaedic surgery, Services Hospital Lahore. About 30 patients having isolated proximal Humerus fracture with age between 40-75 years being treated with promixal humral locking plate were included in the study after permission from ethical review board. Patient with head, spine, abdomen and chest injury or poly trauma were excluded. There were Eight with 2 – part, 15 with 3- part fractures and 7 with 4- part fractures. All these patients were followed at interval of 3 weeks, 6 weeks, 3 months, 6 months and at one year. Results: In all our 30 patients, fracture united 3 months after the surgery. In 05 patients there were screw penetration in the shoulder joint. In these 05 patients, 03 patients developed avascular necrosis (AVN) and underwent shoulder arthroplasty. Loss of reduction was present in 04 patients in whom the revision surgery was done with addition of bone graft. Range of movements were significantly less in patients with 4- part fracture( forward elevation was 95 degree and head shaft angle was 100 degree in these patients while external rotation was 22 to 30, in rest of 35 patients it was within the normal range. Mean DASH score (Disabilities of Arm, Shoulder and Hand) after 6 weeks was 3.2 – 58.4 while after one year at the end of final follow up it was 13.3 – 48.6. Conclusion: Our results reveal that PHILOS fixation technique is an acceptable stabilization procedure for proximal humeral fractures. One must be aware of potential hardware complications. For unstable proximal humerus fractures locking plates is a reasonable option especially in 3- part and 4- part fractures in osteoprotic bone. But at the same time it has got high complication rate like screw penetration in the joint, loss of fracture reduction and varus malunion etc
FREQUENCY OF ANEMIA IN THE FIRST TRIMESTER OF
PREGNANCY AND COMPARISON OF PHYSIOLOGICAL
SYMPTOMS OF PREGNANCY AMONG ANEMIC AND NON ANEMIC PATIENTS IN A PRIMARY HEALTH CARE CENTER: A COMPARATIVE CROSS-SECTIONAL STUDY
Zaeem Sohail Jafar, Aniq Ahmed, Khalida Ahtesham, Momina Rasheed, Anum Hayat
https://doi.org/10.59058/jaimc.v21i1.73
ABSTRACT
Background & Objective: Anemia in pregnancy accounts for one-fifth of maternal deaths worldwide and is associated with high maternal morbidity, mortality, and adverse pregnancy outcomes. Pregnancy is associated with a variety of physiological symptoms, which can be distressing and need to be managed. Hence in this study, we aim to determine the frequency of anemia and compare the physiological symptoms in the first trimester of pregnancy among anemic and non-anemic patients. Methods: A cross-sectional comparative study was conducted on women attending a rural health center in Pakistan for their first antenatal visit from January to November 2021. A formal interview of 801 eligible participants was conducted by the investigator to determine pregnancy-related symptoms and demographic data. Hemoglobin, and urine analysis reports were obtained from the hospital's laboratory. Data were analyzed using SPSS. Results: The mean age of participants was 27.2 ± 4.6 years and mean Hb levels were 9.82 ±0.66 g/dl. The overall frequency of anemia was 96.5%. Majority were mildly anemic (71.5%), 5.9% were moderately anemic, and 0.3% were severely anemic. It was seen that anemic females experienced more symptoms in the first trimester compared to non-anemic females i.e. 492 (63.6%) vs 12(42.8%) respectively. Nausea and vomiting were the most common symptoms reported in 190 (23.7%) females. Heartburn was reported in 117 (14.6%), urinary tract infection (UTI) in 97 (12.1%), constipation in 39 (4.9%), backache in 33 (4.1%) and 28 (3.5%) women reported pelvic pain in the first trimester. Conclusion: There was a high prevalence of anemia among pregnant women along with higher frequency of symptoms in the first trimester which calls for awareness and education in the community. The most common symptoms found in our population were nausea and vomiting, followed by heartburn and urinary tract infection.
CORRELATION OF ACTUAL TIME SINCE DEATH WITH
ESTIMATED TIME OF DEATH BY MEASURING PROTEINS
CONCENTRATION IN CADAVERIC CEREBROSPINAL FLUID
Arooj Ahmad, Shabbir Hussain Chaudhry, Umar Farooq, Iqra Waheed, Ayesha Junaid, Anam Ali
https://doi.org/10.59058/jaimc.v21i1.109
ABSTRACT
Background & Objectives: Postmortem Interval (PMI) is the time interval from death upto conducting autopsy of deceased. PMI is an overbearing perspective of medical jurisprudence used to support beholders claim, corroborate the potential in provided proof and serve as evidence for further action. The objective of this study is to estimate the time since death by measuring proteins concentration in cadaveric cerebrospinal fluid. Methods: This cross-sectional study conducted at Forensic Medicine and Toxicology Department of Allama Iqbal Medical College, Lahore for 1 year from January 2022 to January 2023 in 50 dead bodies included through non probability consecutive sampling. After informed consent, CSF sample was taken by using lumbar puncture technique and quantitative values of proteins were obtained automatically through auto- biochemical analyzer. Data were analyzed through SPSS version 25. The relation between time of death and time estimated on CSF proteins was measured by calculating Pearson's correlation coefficient. P-value ≤0.05 was taken as statistically significant. Results: Out of 50 bodies, 25 (50%) were male bodies and 25 (50%) were female bodies. The female to male ratio was 1: 1. Mean actual time of death was 73.46 ± 33.82 hours, while the estimated time of death on CSF protein assessment was 71.54 ± 31.92 hours. The mean CSF fluid level was observed was 170.26 ± 88.61 mm3. A significantly strong positive correlation was observed between time estimated by using protein level in CSF fluid and actual time of death i.e. r =0.952 (p-value <0.0001).
PATTERN OF SELF-POISONING AND TOXICITY IN SUICIDAL DEATHS PRESENTING FOR AUTOPSY AT THE TEACHING HOSPITAL OF THE COSMOPOLITAN CITY OF PAKISTAN
Arooj Ahmad, Shabbir Hussain Chaudhry, Umar Farooq, Iqra Waheed, Ayesha Junaid, Anam Ali
https://doi.org/10.59058/jaimc.v21i1.110
ABSTRACT
Background & Objective: Suicide is a common cause of death among teenagers and young adults and day by day, an increase has been observed in this trend. In most cases, home-based materials are used for this purpose. Hence, we aim to determine the frequency of various poisonous agents used for suicide and the pattern of presentation of such suicidal death for autopsies at a teaching hospital in a cosmopolitan city of Pakistan. Methods: This cross-sectional study was conducted at the Toxicology and Forensic Medicine Department, Allama Iqbal Medical College, Lahore over a 1-year period from January 2022 to January 2023. About 60 dead bodies of deceased committing suicide were included through non probability consecutive sampling. Poisonous material used for suicide was inquired from family or next of kin and was verified with a toxicology report. Data was then recorded in proforma and analyzed in SPSS version 25. Results: The mean age of dead bodies at the time of death was 29.51 ± 14.92 years. There were 37 (61.7%) male bodies and 23 (38.3%) female bodies. The mean duration between death and body received for autopsy was 2.4 ± 1.7 days. Out of 60 cases, 37 (61.7%) cases had a history of depression before suicide, 6 (10.0%) were taking anti-psychiatric treatment, 2 (3.3%) had schizophrenia, 4 (6.7%) had depressive disorder, while 11(18.3%) had no depressive symptoms or relatives were unaware of that. Out of 60 cases; 12 (20.0%) committed suicide with organophosphates, 10 (16.7%) took over-the-counter drugs, 8 (13.3%) ingested household chemicals or acid, 6 (10.0%) took kala pather, 6 (10.0%) ingested wheat pills, 5 (8.3%) took cocaine in overdose, 5 (8.3%) had methamphetamines overdose, 3 (5.0%) had cannabinoids, 2 (3.3%) had methadone, 2 (3.3%) benzodiazepines and 1 (1.7%) had alcohol overdose. Conclusion: Organophosphate (pesticide) is the most commonly used suicidal poisoning agent, followed-by household acids in cosmopolitan cities (urban areas). Stringent regulations are needed to regulate the sale of these toxic materials to avoid unnatural deaths of our youth.
SOCIO-CULTURAL BARRIERS AND HEALTH SEEKING
BEHAVIOR AMONG FEMALE PATIENTS OF TUBERCULOSIS IN
SOUTHERN PUNJAB
Muhammad Anwar, Aftab Iqbal, M. Bilal Anwar, Sana Abbasi, H.M.Dawood, Imtiaz Warraich, M. Awais Anwar, Junaid Mirza
https://doi.org/10.59058/jaimc.v21i1.50
ABSTRACT
Background & Objective: In Pakistan, some societies consider a woman's place is at her home, and they are discouraged to visit the outside home including health facilities. Due to these societal restrictions, many health problems remain undiagnosed and untreated. According to the latest TB trends, the female ratio in smear-positive cases is increasing each year worldwide, which is a serious threat. Hence, we aim to assess the socio-cultural barriers faced by the women and their health seeking behavior for TB. Methods: This cross-sectional descriptive study was carried out in two District Hospitals in southern Punjab (Muzaffargarh and DG khan). About 190 females patients with tuberculosis registered at the TB clinic were selected through simple random sampling. An interview was conducted and the responses were recorded in a structured questionnaire. Data were entered and analyzed using SPSS. Results: Out of 190 patients, a majority 161(85%) of the females claimed that their family and community are reluctant to meet them, 178 (94%) were afraid of leak of information to the community, 112 (59%) were delaying seeking treatment due to stigma, 110(58%) had health facility conveniently located from their residence, however 164 (86%) were not satisfied with the traveling costs. Conclusion: Health-seeking behavior of the female TB patients as well as sociocultural and transport barriers influence the treatment in these patients hence mass education and dedicated health facilities along with transport facilities should be made available to these patients.
CASE REPORT
PREMENOPAUSAL AND POSTMENOPAUSAL UTERINE LIPOLEIOMYOMA; A REPORT OF TWO CASES
Muhammad Hassnain Nasrullah, Muhammad Hassan, Muhammad Jawad Haider, Muhammad Imran
https://doi.org/10.59058/jaimc.v21i1.99
ABSTRACT
Background & Objective: Uterine lipoleiomyoma are extremely rare variants of leiomyoma. Postmenopausal women frequently develop these types of tumors. but we also have a case of pre-menopausal woman. Ultrasound and CT scan findings may be nonspecific, but The use of MRI prior to surgery can be beneficial in detecting fatty tissue in the lesion. Diagnosis is usually confirmed postoperatively through histopathological examination. Methods: Two cases were reported. A 60 years old postmenopausal woman with mass in the abdomen presented at Jinnah Hospital Lahore with differential diagnosis of Ovarian teratoma, Leiomyoma sarcoma, non-teratomatous lipomatous ovarian tumor, pelvic sarcoma, and lipomatous malignancy. Another case was reported involving a premenopausal woman who was 53 years old and presented with pelvic pain, irregular bleeding and a mass in the lower abdomen. Result: Postoperative excision biopsy report showed a rare pathology of Lipoleiomyoma. Conclusions: Lipoleiomyomas are clinically rare with most common occurrence in uterine corpus. They have excellent prognosis and but a long-term follow- up of patients is required to observe its potential for coexisting malignancies and metabolic disorders