Smoking, once again

I thank Dr. Al Moamary for designating an editorial and ringing the bell on the smoking epidemic in the Kingdom of Saudi Arabia (KSA).[1] The smoking statistics that he has quoted are indeed worrying. Strikingly, although KSA has a population over 20 million, it is the fourth in the world in terms of tobacco consumption and sales. Health institutions are already receiving a significant number of smoking victims and are expected to be overwhelmed when the epidemic manifests itself as the current smoking population advances in age.


Smoking, once again
Sir, Commentary on Tobacco consumption: Is it still a dilemma? I thank Dr. Al Moamary for designating an editorial and ringing the bell on the smoking epidemic in the Kingdom of Saudi Arabia (KSA). [1] The smoking statistics that he has quoted are indeed worrying. Strikingly, although KSA has a population over 20 million, it is the fourth in the world in terms of tobacco consumption and sales. Health institutions are already receiving a significant number of smoking victims and are expected to be overwhelmed when the epidemic manifests itself as the current smoking population advances in age.
More is needed to control the smoking epidemic, in particular, enforcing the smoking ban, raising the taxes (which is one of the lowest in the world), and pursuing the tobacco companies legally.
The objectives of smoking ban in public places is to protect non-smokers (innocent bystanders) from risks of second hand smoking (SHS), and to make smoking more difficult for smokers which may help them to quit or at least reduce smoking. As far as SHS is concerned, more worrying stastics have come recently from WHO showing a yearly death toll over 600, 000 worldwide, 165, 000 of which are amongst children. [2] I would like here to complement Dr. Al Moamary's editorial, by clarifying the situation of the smoking ban in KSA. Although the anti-smoking law in KSA was passed nearly 10 years ago by Al Shoura Council, [3] unfortunately it has not been yet activated. Only recently (November 2010), the smoking ban was enforced in airports, which is a positive step forward. Some places, such as King Saud University and few shopping malls have voluntarily established their own anti-smoking policies, a step they should be thanked for. However, the force of law is yet to reach thousands of public places such as restaurants, coffee shops, parks, and work places where smoking goes on unnoticed.
Physicians, especially in thoracic medicine, are the most able people to appreciate the considerable suffering that victims of smoking endure, as well as the health and economic burden on the country. Therefore, they should take an active role in the tobacco control. This year (2010) has been declared as the year of the lung by a number of international respiratory societies. [4] Through their professional societies, in particular, the Saudi Thoracic Society (STS) and Saudi Heart Association (SHA), physicians in KSA should lobby to enforce the antismoking law in public places and support all other measures to control this epidemic. Those involved in academic institutions need to engage in more research on all aspects pertaining to smoking, whether it is epidemiological surveys, psychology of the addiction, or newer therapies, including vaccines. With the preponderance of research chairs at universities nowadays, I dream of a research chair designated to tackle smoking

Filarial pleural effusion
Sir, I read the article of Garg, et al. [1] with great interest. As a coauthor of our work [2] cited in their article, I would like to make it clear that the microfilariae detected in the pleural biopsy material of our case were of Wuchereria bancrofti and not Mansonella perstans as quoted in the text by the authors. I was surprised to note that the closed pleural biopsy was not carried out as there was a chance to establish the filarial etiology within the pleura. Microfilariae reside in the arterioles of pulmonary system during daytime and appear in peripheral blood and other body fluids only in the night time during the peak biting time of mosquito vectors. The traditional diagnostic method of filariasis is to demonstrate microfilariae microscopically in the peripheral blood (capillary finger prick or thick venous blood smears) drawn in the night or presence of circulating filarial antigen. [3] Filariasis is a major health problem in India and microfilariae have been detected along with other diseases such as tuberculosis, non-Hodgkin's disease, etc. [4] I am curious to know the scientific basis regarding the number of times a clinical specimen like pleural fluid can be tested and methodology adapted by the authors who successfully demonstrated microfilariae on all four occasions to conclude that the pleural effusion was due to filariasis only.

What dose of antisnake venom should be given in severe neuroparalytic snake bite?
Sir, Indian cobra (Naja naja) and Common Indian krait (Bungarus caeruleus) are two important species of elapid snakes found in India and are responsible for most of the cases of neurotoxic snake bite. Respiratory failure is the most important cause of morbidity and mortality in victims of neurotoxic snake bite. [1,2] Cobratoxin and α-bungarotoxin act postsynaptically by binding to acetylcholine receptors on the motor end plate while β-bungarotoxin and crotoxin act presynaptically and prevent release of acetylcholine at the neuromuscular junction.
Timely administration of anti-snake venom (ASV) along with cardiorespiratory support is the only effective treatment available for neurotoxic snake bite. [3,4] ASV is the most effective when administered early enough to neutralize venom in the circulation before it reaches the target site. However, there is no universal consensus on the optimal dose and protocol of ASV administration. Higher doses of ASV had been used earlier with the hope of early recovery. [5] Other investigators have found no significant difference on survival outcome and duration of ventilation while comparing high dose ASV regimens with low dose ASV regimens. [6] Fifty-eight patients with severe neurotoxic snake bite with respiratory failure were admitted to MICU during the study period. Of this there were 41 males and 17 females. The Letters to the Editor