Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Evaluation of Efficacy of Levetiracetam in treating Neonatal Seizures in DHQ Hospital, Pakistan

OBJECTIVE: evaluate the frequency of efficacy of Levetiracetam in treating seizures in neonates METHODOLOGY: In this descriptive observational study, we enrolled 110 cases from DHQ Hospital Kasur. We included all neonates of either gender, term cases, with seizures, loading dose of 50 mg/kg of intravenous levetiracetam was given at admission and maintained on a dose of 25 mg/kg every 12 hours. Outcome was measured in-terms of loss of EEG event within 72 hours of treatment and cessation of tonic, clonic seizures in ? 12hours. RESULTS: Out of 110 cases, 42.73%(n=47) were between 1-15 days of life and 57.27%(n=63) were between 16-28 days, 48.18%(n=53) were male and 51.82%(n=57) were females. The efficacy of the Levetiracetam in neonatal seizures was recorded in 62.73%(n=69) neonates. Conclusion: LEV is an effective drug for resolving neonatal seizures in our population.

Psychological Predictors of Anxious Responses to the COVID-19 Pandemic: Evidence from Pakistan

Objective@#COVID-19 epidemic can be associated with a variety of anxious responses and safety behaviors. The present research explored the psychological implications associated with COVID-19 during the outbreak in 2020 to date. Pakistani media has given particular attention to this outbreak in the region. @*Methods@#Three hundred and forty-seven undergraduate university students from Pakistan completed a battery of questionnaires focusing fear of COVID-19, associated safety behaviors, factual knowledge of COVID-19, and other psychological pointers hypothesized to be as predictors of anxious responses to COVID-19 threat and associated safety behaviors. @*Results@#The sample appeared to be fearful of COVID-19 and this fear was related to disgust sensitivity, anxiety sensitivity-related physical concerns, body vigilance, contamination cognitions, and general distress. Results suggested that the tendency of overestimating the severity of contamination and anxiety sensitivity towards physical concerns are significant predictors of COVID-19 related fear and consequent safety behaviors. @*Conclusion@#It is suggested that people with a greater concern of contamination are likely to respond fearfully to COVID-19 and that people with higher fear of COVID-19 are likely to feel contamination concerns.

Component Alignment in Simultaneous Bilateral versus Unilateral Total Knee Arthroplasty

PURPOSE: The purpose of this study was to investigate differences in component alignment between first and second knees in simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral TKA (UTKA). MATERIALS AND METHODS: 274 SBTKAs and 198 UTKAs were included in study. Patients were divided into three groups as SBTKA on the right knee (group A), SBTKA on the left knee (group B) and UTKA (group C). Femoral and tibial component alignment was checked in both coronal plane (alpha [α] and beta [β] angles) and sagittal plane (gamma [γ] and delta [δ] angles) radiographs. RESULTS: There were no statistically significant differences among groups in the preoperative anatomical varus angle and Kellgren–Lawrence gonarthrosis classification grade (p=0.139 and p=0.329, respectively). In the coronal plane, the alignment of femoral component (α angle) and tibial component (β angle) was similar in all three groups (α angle, 95.01 vs. 95.14 vs. 94.9, p=0.945; β angle, 90.03 vs. 89.67 vs. 89.98, p=0.483). The sagittal plane alignment of femoral component (γ angle) and tibial component (δ angle) did not show significant differences (γ angle, 7.04 vs. 6.98 vs. 7.00, p=0.132; δ angle, 86.56 vs. 87.41 vs. 86.73, p=0.610). CONCLUSIONS: The angular alignment of components was similar between SBTKA and UTKA.

Development and in vitro characterization of niosomal formulations of immunosuppressant model drug

Among immunosuppressive agents cyclosporine A is drug of unique importance. This drug has a low therapeutic index, and it has many toxic effects. After oral administration its absolute bioavailability is variable due to poor absorption. Niosomes are new and versatile carriers to deliver drug. The bioavailability of immunosuppressant drug cyclosporine A can be increased by niosomal drug delivery system. So our basic theme was to prepare niosomes of immunosuppressant drug using cholesterol, span 60 and tween 60 etc. Niosomes were characterized for zeta potential, size, poly dispersivity index [PDI], entrapment efficiency and In vitro release profiles. Six niosomal formulations [F1-F6] were successfully developed using thin film hydration technique. Among various formulations F2 showed the highest entrapment efficiency 77.29 %. The DSC thermograms of physical mixtures and niosomal formulations indicated the presence of drug in crystalline form. In vitro drug release study demonstrated higher drug release values as compared to drug aqueous dispersion. Niosomal formulations were capable of releasing drug in sustained manner. The overall results demonstrated that developed niosomal carriers are competitive candidates for improving dissolution profile of cyclosporine A leading to increased bioavailability at the site of action

Thoracic impalement injury: A survivor with large metallic object in-situ / 中华创伤杂志(英文版)

Impalement injuries, is a severe form of trauma, which are not common in civilian life. These injuries rarely occurs in major accidents. Abdomen, chest, limbs and perineum are often involved due to their large surface area. Thoracic impalement injury is usually a fatal injury, due to location of major vessels and heart in the thoracic cavity. These injuries are horrifying to site, but the patients who are lucky enough to make it to hospital, usually survive. Chances of survival are larger in right sided impalement injuries while central injuries are always died at the scene. Our patient, 25 years old male, was brought to the emergency room (ER) with large impaled metallic bar (about 2.5 feet long) in situ, in right sided chest. The patient was immediately shifted to operation room (OR) and was operated, his recovery was uneventful without any sequelae. Such patients should be treated and resuscitated according to advanced trauma life support (ATLS) protocols and operated without any delay for further investigations. Such operations are carried out by the most experienced surgeon team available. The impaled objects should not be processed if not necessary to avoid major hemorrhage and damage to vital structures, until the patient is in operation room. Large size and unusual position of impaled objects, makes the job difficult for surgeons/anesthetists. Although horrifying at scene, patients with thoracic impalement injuries are mostly young and healthy, and those who survive the pre-hospital phase are potentially manageable with proper resuscitation. Usually these patients make recovery without any further complications.

Serotonin syndrome and liver failure with duloxetine overdose

We present a unique case of serotonin syndrome and acute liver failure associated with Duloxetine overdose in a young female. This pathological combination has not been reported previously with this medication and in our opinion deserves attention of medical community. Duloxetine use has increased exponentially over the years, putting significant patient population at risk of side effects from this drug

Comparison of chest percussion in supine with quarter prone position to reverse gravitational atelectasis among mechanically ventilated COPD patients

Objective. To compare the clinical outcome measures of chest percussion in supine with quarter prone position, in terms of changes In Fi02, heart rate[HR] respiratory rate[RR], peak pressures and SpO2 to resolve gravitational atelectasis among mechanically ventilated COPD patients

Methods: This is a Comparative cross sectional study in which 42 COPD patients with gravitational atelectasis were selected using convenient sampling and divided into two equal groups of21 participants in each group. Group A was provided with [CPT] in supine position while group B was with chest percussion in quarter prone position. Clinical outcome measures like FiO2, SpO2, respiratory rate, heart rate and peak pressure were measured before and after the treatment

Results: The mean age of the patients in group A was 58.71 +/- 956 years whereas in group B was 52.47 +/- 8.81 years. Using the paired t-test it was analyzed that before and after the treatment, there was significant difference in Sp02, respiratory rate, heart rate and peak pressure as the p value was highly significant [p-value=0.000] but no significant difference in FiO2 [p-value=0.08] in both groups. Paired sample t-test was applied for post treatment difference of Fi02, Sp02, RR, HR and peak pressure between group A and group B , showed no significant difference as the p value was not significant

Conclusions: Chest percussion was equally effective in both positions to resolve gravitational atelectasis by clearing the airways and improving oxygenation

Preventive Gabapentin versus Pregabalin to Decrease Postoperative Pain after Lumbar Microdiscectomy: A Randomized Controlled Trial

STUDY DESIGN: Randomized controlled trial. PURPOSE: The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital. OVERVIEW OF LITERATURE: Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery. METHODS: This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively. RESULTS: Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R²=0.018). CONCLUSIONS: Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed.

Comparison of short-term efficacy of leflunomide and methotrexate in active rheumatoid arthritis

Objective: To compare short-term efficacy of Leflunomide and Methotrexate in active rheumatoids arthritis

Methodology: This study, a randomizeds controlled trial, was conducted at Medical B Unit, Postgraduate Medical Institute Lady Readings Hospital, Pe-shawars over a one year period, from 1[st] June 2014 to 31[st] May 2015. 294 patients with active RA [DAS28>5.1] were randomized via lottery methods to Leflunomide 20mg daily [n=147] and Methotrexate [n=147]. Efficacy of either drug at 6 months of treatment was assessed in terms of DAS 28 scoring as per European League Against Rheumatisms [EULAR] criteria

Results: After 66 months of treatment with Methotrexate, 110 out of 147 [74.82] patients had a moderate response as per EULAR criteria [DAS 28 improvement of >1.2] 37 patients had no response. In Leflunomide group, 100 [68.02%] patients had moderate response and 47 patients had no response. The difference in those achieving moderate response for both groups was statistically not significant [p=0.24]. The mean change in DAS 28 score for Methotrexate group was 1.89 +/- 0.77 while that for Leflunomide group was 1.79 +/- 0.75. The difference in change of DAS 28 score for both groups was statistically not significant [p=0.23]

Conclusion: There is no statistically significant difference between short-term efficacy of Leflunomide and Methotrexate in patients with RA

Ogilvie's syndrome

Ogilvie's syndrome, also known as 'paralytic ileus of the colon', is characterised by pseudo-obstruction of the large intestine in the absence of any mechanical obstructing component; and presents as a massively distended abdomen. If left untreated, it may lead to bowel perforation or ischemia. Ogilvie's syndrome usually presents as a postsurgical complication, mainly due to the lack and/or restriction of movement coupled with a possible electrolyte imbalance. Here, we present a case of a pre-surgical 63-year lady, having a right hip fracture, who came with complaints of severe abdominal pain and distension for 4 days. Abdominal X-rays showed massively dilated bowel loops. Patient was successfully managed with neostigmine administration and was discharged home

Response to: Computed Tomography-Guided Biopsy for Potts Disease: An Institutional Experience from an Endemic Developing Country

No abstract available.

Abdominal Pain, dysentery and bilious vomiting: An atypical presentation of henoch schonlein purpura: a case study

Adolescent male resident of Hazara, Pakistan presented with abdominal pain, bilious vomiting, dysentery and knee pain of 10 days duration in July of 2014 to the emergency department of the Aga Khan University Hospital. Knee pain later migrated to ankle and was associated with redness and oedema. Abdominal x-ray revealed thickened bowel wall that was suggestive of enteritis. He was being treated with IV antibiotics [ceftriaxone and metronidazole], which did not help in resolving his symptoms. Overnight he started developing palpable rashes on his feet, back and abdomen, which raised the suspicion of Henoch-Schonlein purpura. There were no signs to suggest any respiratory and urinary systems involvement. He was given intravenous prednisolone after which his rashes dramatically disappeared and his ankle pain and other symptoms resolved. On follow up his lab investigations were within normal range with complete disappearance of rash and resolution of his abdominal pain, dysentery and bilious vomiting. Rarely dysentery is accompanied with palpable rashes and should raise suspicion of Henoch-Schonlein Purpura. Knowledge and understanding of this rare disease can help early diagnosis and initiate prompt treatment

Computed Tomography-Guided Biopsy for Potts Disease: An Institutional Experience from an Endemic Developing Country

STUDY DESIGN: A retrospective chart review. PURPOSE: In endemic resource poor countries like Pakistan, most patients are diagnosed and treated for Potts disease on clinical and radiological grounds without a routine biopsy. The purpose of this study was to evaluate the use and effect of computed tomography (CT)-guided biopsy in the management of Potts disease since the technique is becoming increasingly available. OVERVIEW OF LITERATURE: CT-guided biopsy of spinal lesions is routinely performed. Literature on the utility of the technique in endemic resource poor countries is little. METHODS: This study was conducted at the Neurosurgery section of Aga Khan University Hospital Karachi. All the patients with suspected Potts disease who underwent CT-guided biopsy during the 7 year period from 2007 to 2013 were included in this study. Details of the procedure, histopathology and microbiology were recorded. RESULTS: One hundred and seventy-eight patients were treated for suspected Potts disease during the study period. CT-guided biopsies of the spinal lesions were performed in 91 patients (51.12%). Of the 91 procedures, 22 (24.2%) were inconclusive because of inadequate sample (10), normal tissue (6) or reactive tissue (6). Sixty-nine biopsies were positive (75.8%). Granulomatous inflammation was seen in 58 patients (84.05%), positive acid-fast bacillus (AFB) smear in 4 (5.7%) and positive AFB culture in 12 patients (17.3%). All 91 cases in which CT-guided biopsy was performed responded positively to antituberculosis therapy (ATT). CONCLUSIONS: 75.8% of the specimens yielded positive diagnoses. Granulomatous inflammation on histopathology was the commonest diagnostic feature. In this series, the rates of positive AFB smear and culture were low compared to previous literature.

Reconstruction of non-melanotic facial tumours with local flaps; replacing like with like

To assess the outcome of early skin tumour excision and reconstruction with regards to tumour margin clearance, recurrence and aesthetic results of reconstruction. Quasi experimental. This study was carried in the department of Plastic and Reconstructive Surgery Combined Military Hospital [CMH] Rawalpindi, Pakistan from January 2010 to December 2012. All patients having tumours of the cheek, upper and lower lips, nose and forehead, who underwent primary surgical excision and reconstruction with local flaps, were included in the study. Patients with nodal or distant metastasis were excluded. Tumours were excised with safe margins and defects reconstructed with local facial flaps. Patients were regularly followed up as per protocol for basal cell carcinoma [BCC] and squamous cell carcinoma [SCC]. Eighty nine patients aged between 37-86 years with a mean age of 59.4 years [SD +/- 9.24] were included in the study. There were 58 [65%] cases of basal cell carcinoma [BCC] and 31 [35%] of squamous cell carcinoma [SCC]. Recurrence was seen in 3 [5.2%] cases of BCC and 2 [6.4%] cases of SCC. There was 1 [1.1%] complete and 4 [4.5%] partial flap losses. The follow-up period ranged from 4 months to 3 years with average of 16 months. Local flaps give a simple option for facial reconstruction for postoncological resection defects giving good aesthetic match due to local tissue

Lumbar Morphometry: A Study of Lumbar Vertebrae from a Pakistani Population Using Computed Tomography Scans

STUDY DESIGN: A cross-sectional study. PURPOSE: To describe the characteristics of lumbar vertebrae of Pakistani patients reporting at a tertiary care hospital and compare with studies from other populations. OVERVIEW OF LITERATURE: Several studies have been conducted to determine morphometry of lumbar vertebrae. Most of the studies involve Caucasian populations, still data on other populations still sparse. This is the first study describing lumbar morphometry of a Pakistani population. METHODS: An observational study was conducted based on a review of thin-cut (3 mm) computed topographic images of lumbar vertebrae. Two-hundred and twenty vertebrae from forty-nine patients were studied, and various dimensions were analyzed. RESULTS: Generally, the size of the vertebrae, vertebral canals and recesses were found to be greater in male patients. The difference was statistically significant for transverse and anteroposterior diameters of the vertebral bodies and sagittal diameter of pedicles on the left side (p<0.05). Comparison of populations revealed statistically significant differences in pedicle dimensions between Pakistani population and others. CONCLUSIONS: This study provides anatomical knowledge of the lumbar region in a sample population of Pakistan. There were significant differences in various dimensions of lumbar vertebrae between female and male patients. This would prove to be critical for performing a safe operation.

Relationship of alloantibody detection with number of blood transfusions

To study the presence of the alloantibodies and their relationship with the number of transfusions. Two hundred subjects undergoing regular blood transfusions with at least 5 pints of blood within last six months were included in the study. Out of 200 patients, 140 [70%] were transfusion depended thalassaemics, 20 [10%] were haemophilics receiving multiple transfusions, 20 [10%] patients were of aplastic anaemia and 20 [10%] patients were with chronic renal failure undergoing haemodialysis. Antibodies were detected in 9/200 [4.5%] subjects. Ninety four patients received 5-50 transfusions, 2.13% developed alloantibodies. Sixty five patients received >50-100 blood transfusions, 6.15% developed alloantibodies. Forty one patients received >100 blood transfusions, 7.31% developed alloantobodies. Frequency of red cell alloantobodies in our transfusion dependent patient population is 4.5%. The risk of developing alloantobodies increased with increasing number of blood transfusion irrespective of underlying disorder.

Management of war injuries - experience at CMH Rawalpindi during 2008 - 2010

To see the changing mode of injury from firearm to blast, pattern of injury with modern body armor and improved surgical options with results of different procedures done. Descriptive study. Department of Plastic Surgery Combined Military Hospital Rawalpindi between Jan 2008 and Dec 2010. All victims of low intensity conflict whether civilian or military personnel from all age groups without sex discrimination were included. Data was collected from history, transferring notes from the forward medical facility to this hospital, case record documents in this hospital and `patients follow up proforma. All these cases were managed in collaboration with other concerned specialties including orthopedic surgery, general surgery, otolaryngyology, maxillofacial surgery and vascular surgery. Plastic surgery department managed 212 patients over last three years i.e. 2008-2010. Age range was 14-58 years and male to female ratio was 71:1. Primary surgical wound management was done at field military hospitals in majority of cases and few were air evacuated directly to CMH Rawalpindi. Majority of injuries were caused by explosions followed by firearms. Simultaneous injuries were 68.9% and isolated injuries were 31.1%. Decision of wound closure was usually dependent on level of tissue damage, contamination and infection. Concept of reconstructive ladder was followed. Majority of wounds were closed in delayed primary setting. Infection was the most common complication followed by partial or complete graft or flap loss. Minimum complication rate was encountered in the wounds which were closed in delayed primary setting. All war wounds are primarily contaminated. If these wounds are closed in delayed primary setting after 2-3 debridements, best results can be achieved. Although infected wounds, wounds with severely damaged structures and injuries associated with tendon or nerve injuries or bone loss will require secondary reconstructive procedures.

Comparative study - trans-septal basting suture vs nasal packing after submucoperichondrial resection

To compare the effectiveness of nasal packing vs basting [quilting] suture in the control of postoperative bleeding and or haematoma formation and patient compliance of nasal packing after Submucoperichondrial Resection [SMR]. Comparative clinical trial with stratified randomization. Department CMH Kharian cantt from January, 2006 to March, 2007. A total of 200 patients were included in the study. One hundred cases had basting suture and 100 had nasal packing. Patients requiring other procedures like cautery, submucosal diathermy, turbinectomy and middle meatal antrostomy were excluded. The two groups were compared for postoperative bleeding, septal haematoma formation, discomfort in nose, and general well being. Patients with basting suture were free of any discomfort postoperatively which was seen in cases with nasal packing. The two methods were equally effective in preventing excessive bleeding and septal haematoma formation. We conclude that the basting suture technique avoids the patient from post operative discomfort caused by nasal packing and is equally effective in preventing post operative septal haematoma. As the post-op discomfort is significant in nasal packing we recommend quilting of the mucoperichondrial flaps.

Analgesic effect of transversus abdominis plane [TAP] block for abdominal surgery: comparison with standard post operative care

To compare post operative pain in patients undergoing TAP block with that of standard post operative care in patients undergoing abdominal surgery. Fifty patients [21 males, 29 females] with ASA class I and II undergoing abdominal surgery were included in the study. Half of the patients selected through randomization received TAP block using landmark technique at the end of surgery under anaesthesia. The remaining half received standard post operative analgesia with nalbuphine and diclofenac sodium injections. All patients were questioned regarding the degree of analgesia on a Pakistan Coin Pain Scale till 12 hours post operatively. Use of analgesics was compared in the two groups postoperatively. The degree of pain was significantly lower in patients receiving TAP block compared with standard postoperative care [mean score 06 vs 16 p<0.05]. The quantity of nalbuphine [0.32 vs 4.08 p<0.01] and diclofenac sodium [9.0 vs 63 p<0.01] were significantly reduced in patients receiving TAP block compared with standard post operative care. Transversus abdominis plane block provides effective post operative analgesia and is associated with markedly reduced analgesic consumption