Trends in prescribing antiplatelet drugs for secondary prevention of non-cardioembolic ischemic stroke

Objective: To determine the trends of physicians and neurologists in prescribing anti-platelet agents for secondary prevention of non-cardio embolic stroke after 3 months of stroke

Study Design: A descriptive study

Place and Duration of Study: Combined Military Hospital [CMH] Lahore over a period of four months

Material and Methods: Patients suffering from old [>/=3 months] non-cardio embolic stroke, taking anti-platelet agents for secondary prevention and visiting CMH Lahore neurology clinic. Information about their stroke and treatment was obtained from their previous investigations and medical prescriptions

Results: A total of 60 patients met the inclusion criteria of the study; 36 [60 percent] were taking a combination of clopidogrel 75mg plus Aspirin 75 mg and 12 [20 percent] received Aspirin 75 mg daily while 12 [20 percent] were getting other regimens

Conclusion: Combination of clopidogrel 75mg plus Aspirin 75 mg was the most common anti-platelet regimen prescribed for secondary prevention of non-cardio embolic stroke in our study population

Neutrophil lymphocyte ratio [NLR]: a well assessment tool of glycemic control in type-2 diabetic patients

Background and Objective: Increased neutrophil lymphocyte ratio [NLR] is a marker as well as predictor of various cardiac and non cardiac disorders. Our aim was to assess the relationship between NLR and different level of glycemic control in type 2 diabetic patients

Methods: An observational study was conducted at diabetic clinic of Sheikh Zayed Medical College/ Hospital, Rahim Yar Khan from September 2016 to February 2017 in which 330 type 2 diabetic patients were randomly divided in to three groups based upon diabetes control according to ADA criteria. Patients in group A with HbA1c /= 9 %[ worst control]. Patients were assessed in terms of complete blood count and C - reactive protein

Results: As compared to excellent control [Group A] patients with worst control [Group C]showed a high leukocyte count [p .001], high neutrophil count [P .003] and lower lymphocyte count [P 0.44] while patients in poor control [Group B]did not differ significantly. Similarly value of NLR was also significantly higher in worst control [Group C] as compared to poor control[Group B] and excellent control [Group A] diabetes [4.3+/-2.8, 2.7+/-1.0 and2.0+/-0.5[p.001]. NLR were found independent predictor of worst diabetes control [OR: 1.809, 95% CI: 1.459-2.401] along with fasting blood sugar [OR: 0.938, 95% CI: 0.995-0.982] and CRP [OR: 1.020, 95% CI: 1.003-1.028]

Conclusion: Increased NLR level is associated with elevated HbA1c and poor glycemic control in patients of type 2 diabetes mellitus. It can be used as a disease monitoring tool during the follow up of diabetic patients

Plasmapheresis versus intravenous immunoglobulins in guillain barre syndrome, the therapeutic outcomes

To compare the therapeutic outcomes of plasmapheresis with intravenous immunoglobulins [IVIG] for Guillain Barre syndrome. Randomized controlled trial. Medicine department; PNS Shifa Hospital Karachi from Jan 2011 to Jun 2012. Adult patients admitted to internal medicine department with the diagnosis of Guillain Barre Syndrome [GBS] fulfilling the inclusion and exclusion criteria were included after taking ethical approval and informed consent. They were randomly assigned to plasmapheresis and IVIG treatment groups. Their presenting features, investigations and management plan were followed over 6 months duration. Hughes disability scale for Guillain Barre syndrome was documented and compared at admission, 4 weeks, 12 weeks and 6 months by non-parametric tests via SPSS version 17. Total 36 patients [31 males and 5 females] were included. Mean age was 37 +/- 15 [18-70] years, mean duration of symptoms 11.6 +/- 12.7 days. Plasmapheresis and IVIG groups were comparable with respect to age and gender [p>0.05]. Significant improvement of mean disability score was observed in each group from baseline score [p<0.0005]. At specified intervals, comparison between the two groups in terms of mean improvement in disability scores showed significant improvement at 4 weeks [p<0.05] in IVIG group as compared to plasmapheresis group; however on further observation at 12 weeks and 6 months, mean improvement was comparable between two groups with no significant difference [p>0.05]. There was no significant difference in need for assisted ventilation between two groups [p>0.05]. Variants of GBS observed were AIDP [50%], AMAN [31%] and AMSAN [19%]. Our study suggests that both plasmapheresis and intravenous immunoglobulins are useful and effective modes of treatment for Guillain Barre Syndrome. Significant short term improvement was observed in the IVIG group at 4 weeks of treatment; however no significant difference in therapeutic outcome observed between the two groups on further follow up of 6 months. Thus focusing the need of further large scale regional studies to analyze various factors contributing to this short term but significant improvement with IVIG treatment observed in this study

unusual presentation, pilomatrixoma in the buttock area - a case report

Pilomatrixoma is benign tumor of skin appendages it is rare tumor mainly involving head, neck face and upper extremities. 1 A 16-year-old male developed a lesion, over a period of 2 year, at the middle of right buttock. The presumed diagnosis was a sebaceous cyst / pyogenic granuloma. An excision biopsy was performed and the histopathologic diagnosis was a pilomatrixoma

Melcmotic neuroectodermal tumour of infancy: a rare brain tumour of childhood

Melanotic neuroectodermal tumour of infancy is a rare, mostly benign but locally aggressive tumour of neural crest cell origin occurring in infants. The most commonly affected anatomic site is the maxilla. Such tumours of the brain and skull are very rare. We present the case of an 8 months old baby girl whose presenting complaint was a swelling in the scalp for 6 months. She was otherwise asymptomatic. CT imaging confirmed the presence of an osteolytic tumour in the anterior parasagittal skull with dural involvement. The tumour was surgically excised enbloc. The patient has been well at 2 years follow-up without any evidence of recurrence

Diffuse lung uptake on [99m]Tc-MDP bone scintigraphy-case report

A [99m]Tc-methylene diphosphate [MDP] bone scan of a 35 years old female patient performed for possible skeletal metastasis from carcinoma breast. Diffuse [99m]Tc-MDP uptake was seen in both the lung fields on [99m]Tc-MDP bone scintigraphy. Biochemical and radiological evaluation excluded all the known causes of the diffuse [99m]Tc-MDP lung uptake. Raised serum ferritin levels of 1226ng/ml [normal range for adult female = 13 - 15 ng/ml] was the only abnormal biochemical finding and attributed as the possible cause of lung uptake

Etiological agents of CSOM and its sensitivity pattern

The present study was undertaken with the aim to detect bacteria and fungi as aetiological agent in CSOM and to see susceptibility pattern of bacterial isolates to different antibiotics and to determine the beta lactamase production by the bacterial isolates. Experimental Study. This study was conducted in the department of Microbiology, Basic Medical Sciences Institute, JPMC, Karachi, during the period of August 1998 to February 1999. During this period, 110 patients were seen, of them 62 were male and 48 were female with male to female ratio of 1.3:1. Two swabs were taken from each patients ear, one was put immediately in to Brain Heart Infusion [BHI] broth and the other was inoculated on Sabouraud Dextrose Agar [SDA] slant. BHI was incubated for 2-4 hours and subcultured on blood agar, chocolate agar and MacConkey's agar plates. The Chocolate agar was incubated in 5-10% CO[2] atmosphere in a candle jar and they were incubated for 24 hours at 37°C. SDA slant was incubated for 14 days at 37°C. Isolates were identified by Gram staining and then confirmed by biochemical test. Fungus growth was stained in Lactophenol Cotton blue [LPCB] and identified microscopically. Amongst bacterial isolates gram negative rods [41] and Pseudomonas aeruginosa [45] were predominant. 47 gram positive cocci were seen, of those 37 were Staphylococcus aureus. Fourteen fungal isolates were recovered, all of them were found to be Aspergillus species. Bacterial isolates were tested for beta-lactamase production the drug sensitivity was noted by disc diffusion method on Mueller Hinton agar. Ciprofloxacin and Enoxacin emerged as the most effective antibiotics. Tobramycin also showed good results against gram negative rods and Pseudomonas aeruginosa. Chloramphenicol, Clarithromycin and Minocycline showed good results against Staphylococcus aureus. And other gram positive cocci. Drug sensitivity of the fungi was not done. Micro-organisms showed least sensitivity to Ampicillin and Cotrimoxazole. It is concluded that to achieve the maximum benefits of antibiotics, we must use them with discrimination and with the understanding of microbial population and with the knowledge of their indications and limitations. The indiscriminate, haphazard and halfhearted use of antibiotics and poor follow up of patients causes more harm than good

High altitude headache - an etiological based study

To determine the various causes of headache in patients evacuated from high altitude. Descriptive study An observational hospital based study carried out on 50 soldiers evacuated from Northern Areas to Military Hospital Rawalpindi between Sep 2009 to Mar 2010 for evaluation of headache as their major complaint. Necessary investigations including neuroimaging were carried out in coordination with Department of Neurology, Military Hospital and an appropriate diagnosis was made in each case. The data was analyzed accordingly. A total of 50 patients were analyzed .They were all males and the mean age was 25 years. 52% patients had Acute Mountain Sickness, 12% hypertension, 10% High altitude cerebral edema, 8% Tension type headaches, 6% Dural venous sinus thrombosis, 6% migraine, 2% encephalitis, 2% were of Subarachnoid hemorrhage and 2% patients Hydrocephalus. Acute mountain sickness and high altitude cerebral edema accounts for a significant number of patients with high altitude headache

Comparison of preoperative dose of pregabalin with celecoxib for attenuation of postoperative pain after open cholecystectomy

To evaluate the efficacy of a single preoperative dose of pregabalin in comparison to celecoxib for attenuating postoperative pain after open cholecystectomy. Department of Anaesthesiology, Bolan Medical Complex Hospital, Quetta. Randomized, controlled trial. Sixty adult patients, 35-65 years of age, ASA physical status I or II, of either sex, undergoing elective open cholecystectomy were allocated randomly in this prospective, randomized, controlled study. Patients were randomly divided into two groups of 30 each, to receive either pregabalin 150 mg or celecoxib 200 orally 1 hour before surgery. Postoperative pain was assessed by a 10cm visual analogue scale, where 0 denoted no pain and 10 was taken as the worst imaginable pain. Sedation, postoperative nausea and/or vomiting and any other complication, were assessed periodically throughout the study time. Patients received inj. nalbuphine on demand during the postoperative period and nausea and vomiting were treated with metocloperamide 10 mg. Results were statistically analysed. Cumulative consumption of inj. nalbuphine over 24 hours was 13.5 +/- 7.4 mg for pregabalin group, and 13 +/- 6.7mg for celecoxib group [P >0.05]. No significant difference was found in frequency and severity of postoperative nausea and vomiting [PONV] during 24 hours [P > 0.05], although frequency of sedation was higher in pregabline group [P <0.05]. Preoperative single dose of pregabalin 150 mg provides no better pain relief when compared to celecoxib 200 mg, and high incidence of adverse effects were found in patients receiving pregabline before open cholycystectomy

Hypospermatogenesis and spermatozoa maturation arrest in rats induced by mobile phone radiation

To determine the morphological changes induced by mobile phone radiation in the testis of Wistar albino rats. Cohort study. Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia, from April 2007 to June 2008. Forty male Wistar albino rats were divided in three groups. First group of eight served as the control. The second group [group B, n=16] was exposed to mobile phone radiation for 30 minutes/ day and the third group [group C, n=16] was exposed to mobile phone radiation for 60 minutes/day for a total period of 3 months. Morphological changes in the testes induced by mobile phone radiation for 60 minutes/day caused 18.75% hypospermatogenesis and 18.75% maturation arrest in the testis of albino rats compared to matched controls. However, no abnormal findings were observed in albino rats that were exposed to mobile phone radiation for 30 minutes/day for a total period of 3 months. Long-term exposure to mobile phone radiation can cause hypospermatogenesis and maturation arrest in the spermatozoa in the testis of Wistar albino rats

Wheat pill: clinical characterisitcs and outcome

To determine the clinical characteristics and outcome in patients presenting with wheat pill poisoning. Retrospective study. Department of medicine, Combined Military Hospital, Kharian from 1st July 2009 to 30 December 2010. Fifty two patients with wheat pill ingestion were included in the study. All patients' history, symptoms, signs and management data was collected on a pre-designed data collection form. Mean age was 25.10 +/- 5.35 years with 51.9% females. Time interval between ingestion of pills and presentation to hospital was 2.5 +/- 1.27 hours. Numbers of pills consumed were 2.73 +/- 20. Most common symptom seen in patients was vomiting seen in 88.5% of the patients. Other common symptoms were irritability in 63.5% and confusion in 55.8% patients. Most common clinical sign hypoxia in 75% patients. Overall mortality was 86.5 percent. Wheat pills are highly toxic with rapid and high mortality rate. These patients develop refractory hypotension and metabolic acidosis which progresses to death. More research is required to develop antidote and to minimize toxicity. Strict legislations are required to control sale of aluminium phosphide over the counter

Frequency of axonal variants of guillain-barre syndrome in Pakistan

To determine the frequency of axonal variants in our patients of Guillain-Barre Syndrome. Descriptive study. Department of Neurology, Military Hospital, Rawalpindi and Armed Forces Institute of Rehabilitation Medicine [AFIRM] from 01 Jan 2009 to 30 Jul 2010. Forty adult patients meeting the National Institute of Neurological Disorders and Stroke criteria for Guillain-Barre Syndrome [GBS] were consecutively enrolled in the study. Patient's data, detailed history, examination and electrophysiological studies were carried out and recorded on predesigned proforma. All patients were examined and reviewed by Consultant Physicians and neurologists. Electromyography and Nerve conduction study testing was done by experienced electro-physiologists. Axonal variants of Guillain-Barre Syndrome constituted 16[40%] in our study. The variants of Guillain-Barre syndrome were acute inflammatory polyradiculoneuropathy [AIDP] in 24[60%] patients followed by acute motor axonal neuropathy [AMAN] in 12[30%] and acute motor sensory axonal neuropathy [AMSAN] in 4[10%] patients. We report a high frequency of the axonal variants of Guillain-Barre Syndrome in Pakistan

Risk factors associated with childhood asthma among children aged 1-12 years in Rawalpindi

To explore various risk factors associated with childhood asthma in Rawalpindi garrison and city among children 1-12 years old. Case Control study. Pediatric departments of Military Hospital [MH] and Combined Military Hospital [CMH] Rawalpindi from 1st Aug to 30th Nov 2009. A total of 128 children with diagnosis of asthma presenting in outpatient and indoor pediatric departments of MH and CMH Rawalpindi between ages of 1-12 years were included. Age, gender and socioeconomically matched 112 children without diagnosis of asthma were included as controls. A predesigned questionnaire containing various factors associated with childhood asthma was filled by the researcher by detailed interview with either of parents. Data was analyzed by SPSS version 15 and chi-square test was applied to determine significance. p value <0.005 was considered significant. Out of 15 risk factors studied 8 were found significantly associated with childhood asthma. Significant factors were education of any of the parents more than matric, history of fever at least three times in last year, use of antibiotics, history of hay fever, raised IgE levels, exposure to passive smoking, living in urban areas and family history of asthma [p value<0.005]. Non significant factors were mode of delivery, exclusive breast feeding for more than 3 months, partial breastfeeding for more than 6 months, history of eczema, atopy, history of viral respiratory infections in infancy and less than three number of rooms at home. Male preponderance was noted amongst cases. Education of parents, fever, antibiotics, hay fever, raised IgE levels, exposure to passive smoking, living in urban areas and family history of asthma proved to be significant factors which are similar to those reported in other studies. However, difference was found in other factors. Recognition of these factors can help to optimize management of asthma in children in this area

Comparison between auramine-rhodamine [AR] and Ziehl-Neelsen [ZN] staining in cases of chronic granulomatous lymphadenopathy

Experimental study. This study was conducted at various hospitals of Quetta. This study includes 103 cases of chronic granulomatous lymphadenitis, with 101 cases of tuberculosis lymph nodes amongst a total of 200 cases of non-neoplastic lymphadenopathy.Their ages ranged from 2 to 79 years. Maximum number of cases were in 10-29 years age group. Females [69.31%] were affected more as compared to males. The commonest presenting symptom was fever. Cervical lymph nodes [83 cases] were the commonest site of involvement whereas 18 cases showed multiple site involvement. Fluorescent staining of histopatholigical sections from 103 chronic granulomatous lymphadenitis gave positive results in 76 out of 103 [73.78%] cases, however Ziehl-Neelsen staining was positive only in 29 out of 103 [28.15%] cases. The yield of mycobacteria on fluorescent staining was higly significant [p<0.00l] as compared to Ziehl-Neelsen staining thereby providing the superiority of fluorescent stain. In a total of 200 cases of non-neoplastic lymphadenopathy 101 cases showed granulomatous lesions, histologically consistant with tuberculosis. Other causes of lymphadnopathy were chronic non-specific lymphadenitis [n=87] viral lymphadenitis [n=8], fungal lymphadenitis [n=2] and acute bacterial lymphadenitis [n=2]. Fluorescent staining of histopathological sections from 103 chronic granulomatous lymphadenitis gave positive results in 76 out of 103 [73.78%] cases, however Ziehl-Neelsen staining was positive only in 29 out of 103 [28.15%] cases. In 101 cases, the finding were consistent with the diagnosis of tuberculous lymphadenopathy. In our study, significantly greater number of cases, 78 out of 101 [P<0.001] diagnosed as tuberculous lymphadenitis were in age groups 10-29 years. Female [69.31%] were more affected than males [30.69%]. The common presenting symptom was fever. Cervical lymph nodes were commonest site of biopsy. Haemoglobin estimation in 98 cases revealed anaemia in 65 out of 101 [66.32%] patients of tuberculous lymphadenopathy. Erythrocyte sedimentation rate was performed in 63 cases and was raised in 52 [82.53%] cases. In a total of 80 cases in whom X-ray chest was performed, 14 [15.5%] cases revealed foci of tuberculosis. Thus, in conclusion, this study has highlighted the superiorty of fluorescent stain over ZN stain

Frequency of headache with stress in adolescent and young adults

Objective of this study was to establish a link between stress as a cause of headache in young adults. Cross sectional study. Department of Neurology Military Hospital [MH] Rawalpindi from September 2009 to March 2010. Thirty young patients, referred for the complaints of headache to the Neurology out patient department, were included in this study. A detailed especially designed, pre tested headache questionnaire was devised which was filled for every patient individually included in the study. Twenty One [70%] of the patients in the study group did have the feeling of stress preceding the headache which sometimes persisted during the episode. Nine [30%] did not report any such feeling of stress before or during the episode. Out of the patients reporting stress 71% [15] were female patients and 29% [6] were males. These key findings suggest that stress and headaches may be related for adolescents and young adults and that this relationship may be reinforced over time. Moreover female patients were far more susceptible to this stressful stimulus as compared to the males