Clinical spectrum and outcome of cerebral venous sinus thrombosis in children

Objective: To determine clinical spectrum, neuroimaging finding and outcome of cerebral venous sinus thrombosis [CVST] in children. Study Design: Descriptive and cross-sectional study. Place and Duration of Study: Department of Paediatric Neurology, Children's Hospital and Institute of Child Health, Lahore, from 2015 to 2016

Methodology: Data was collected in a predesigned proforma by non-probability purposive sampling technique from all enrolled 32 patients fulfilling the inclusion criteria. We analysed descriptively the clinical presentation, neuroimaging findings, associated risk factors and outcome. Chi-square test was used to check the association between demographic variables and findings at five percent level of significance

Results: Out of 32 patients enrolled, 75% [24] patients were male; median age was 2.5 years. Fever was found the most common presentation followed by headache and lethargy. Neuroimaging showed superior sagital sinus thrombosis in all [100%], while 25% [8] have additional thrombosis of internal cerebral veins. Ischemic infarction was found in 11 [35%], while hemorrhagic infarction was found in 9 [29%] patients. Death occurred in 6.25% of children

Conclusion: Infections were the common cause of CVST in children followed by anemia and dehydration. Mortality trend was low with earlier diagnosis and aggressive treatment. Anticoagulant treatment along with adequate hydration, antibiotics and correction of anemia can lead to a better outcome. A large local and regional prospective multicenter studies for pediatric cerebral venous sinus thrombosis is suggested to evaluate the risk factors and plan guidelines for managing this condition in children

Fuctional outcome of acute Disseminated Encephalomyelitis in children

Objective: To determine functional outcome of acute disseminated encephalomyelitis in children and factors affecting outcome at The Children's Hospital, Lahore

Study Design: Cross-sectional observational study

Place and Duration of Study: Department of Pediatric Neurology, The Children's Hospital and Institute of Child Health, Lahore from Nov 2014 to Oct 2015

Material and Methods: Fifteen patients with acute disseminated encephalomyelitis fulfilling the inclusion criteria were enrolled. Detailed history, examination, prior febrile illness and modified Rankin scale score for functional disability at presentation and discharge were recorded through study proforma. All patients underwent lumbar puncture and neuroimaging. Data were analysed in SPSS [v.20] and Chi-square test was applied to find p-value

Results: Out of 15 patients, there was male predominance [10 male 66.7 percent] with mean age 7.4 +/- 2.5 years. Encephalopathy 100 percent [n=15] followed by fever, fits 73.3 percent [n=11] and motor deficit 60 percent [n=9] were common presentation. About 46.7 percent [n=7] cases had prior febrile illness. MRI brain had >5 lesions in 86.7 percent [n=13] with sub-cortical area 93.3 percent [n=14] periventricular area 86.7 percent [n=13]. Functional outcome was good in 80 percent [modified Rankin scale of 2 or less at time of discharge]. Consciousness level and disability score at presentation were statistically significant factors affecting the outcome [p-value 0.004 and 0.002 respectively]

Conclusion: Acute disseminated encephalomyelitis in children had variable clinical presentation. It has good outcome with level of consciousness and disability score being significant factors affecting outcome

The cause and neuroimaging findings in pediatric Arterial Ischemic stroke

Objective: To determine the causes of arterial ischemic stroke and neuroimaging findings in children

Study Design: An observational, prospective, cross-sectional study

Place and Dration of Study: Department of Paediatirc Neurology, Children's Hospital and Institute of Child Health, Lahore for a period of six months from Nov 2014 to Apr 2015

Material and Methods: Children from 1 month to 18 years of age with radiologically confirmed arterial ischemic stroke, occurring 1st time in life, were included in the study. Arterial ischemic stroke [AIS] was confirmed on the basis of history, examination and neuroimaging findings of the brain. Further investigations were done according to the cause of arterial ischemic stroke and neuroimaging brain findings

Results: A total of 72 patients of arterial ischemic stroke were identified over a period of 6 months. Among these, male predominance was found in 53 [73 percent] children. Outpatient department patients outnumbered the indoor patients with stroke in 38 [53 percent] children. Children between 1-5 years of age were the most affected ones [65 percent]. Hemiplagia, fits, hemiparesis and aphasia were the most common presenting features affecting 60 [83 percent], 27 [38 percent], 14 [19 percent] and 8 [11 percent] children respectively. The commonest cause of arterial ischemic stroke was iron deficiency anemia, found in 30 percent [n=22] of the children followed by anemia due to other causes in 27 percent [n=20] and congenital heart diseases in 8.3 percent [n=6] of the children. On neuroimaging studies, parietal lobe was the most affected part of the brain in 23 percent of the children [n=16]. Middle cerebral artery was the major artery affecting 57 percent [n=12] of the patients

Conclusion: Iron deficiency anemia, anemia due to other causes and congenital heart diseases were common etiologies in children with arterial ischemic stroke in our study. Parietal lobe and middle cerebral artery were the most affected areas of the brain on neuroimaging

Application of a Collagen Patch Derived from Duck Feet in Acute Tympanic Membrane Perforation

We investigated the utility of the duck-feet collagen extraction patching procedure in the traumatic tympanic membrane (TM) perforation via a comparison with spontaneous healing or paper patch. Fifty-six ears of adult male Sprague-Dawley rats, each weighing in the range of 250 to 300 g, were used for the animal studies. Sixteen rats had one-side ear in the control group and the opposite-side ear in the treated groups. The remaining twelve rats had a one-side ear with the duck-feet collagen patch and the opposite-side ear with a paper patch. The proliferating cell nuclear antigen (PCNA) expression cells were calculated among the 200 basal cells, and the expression percentage was identified as the labeling index. The healing of the perforation in the duck-feet collagen patch group was confirmed to be more rapid compared to the healing of the other groups. PCNA staining was observed in the migrating portion of PCNA enhanced cell to collagen scaffold in Post operative day (POD) 7 of collagen patch group. Thus, the adhesive effect of the duck-feet collagen patch to perforated margin was better than that of the paper patch. After completing the healing process, the collagen patch shrank and detached from the tympanic membrane (POD 14). In this study, we confirmed that the use of a duck-feet collagen patch had the advantage of early healing, inducing natural TM contour, and disappearing ability after the patch effect is complete.

Effect of serum albumin on outcome of stroke in children at tertiary care hospital

Objective: the objectives of this study were to determine the frequency of favorable outcome of stroke in children presenting at tertiary care hospital and to compare the mean serum albumin levels in children with favorable and unfavorable outcome of stroke in tertiary care hospital

Methods: two hundred children in the age range of 1-14 years, meeting the inclusion and exclusion criteria were registered from pediatric and neurology department of Children Hospital and ICH Lahore. Informed consent was taken from their parents to include them in the study. Demographic information [name, age, sex, address] was collected. Serum albumin was sent to biochemistry lab of the hospital at the time of admission. Outcome of the stroke was determined by Modified Rankin Scale at the time of discharge and death in case and observed data was recorded on a specially designed proforma [attached]

Results: in our study, out of 200 cases, 40% [n=80] cases were between 1-7 years of age, 60% [n=120] cases were between 8-14 years of age, mean +/-sd was calculated as 7.75+/-3.49 years, 56% [n=1 12] cases were male, 44% [n=88] cases were females. Frequency of favorable outcome of stroke in children with stroke presenting in tertiary care hospital was calculated as 42.5% [n=85] while 57.5% [n=115] had unfavorable outcome. Comparison of mean serum albumin levels in children with favorable and unfavorable outcome of stroke in tertiary care hospital showed, 3.13+/-0.19g/dl in favorable outcome while 1.79+/-0.18g/dl in unfavorable outcome and p value was calculated as 0.0001 which shows a significant difference between mean serum albumin levels in favorable and unfavorable outcome of stroke

Conclusion: we concluded that most of the pediatric stroke patients have unfavorable outcome and comparatively less patients have favorable outcome of stroke. Also, the mean serum albumin level in children with favorable outcome is higher and it is significantly lower in children with unfavorable outcome of stroke in tertiary care hospital. So higher the serum albumin in pediatric stroke patient one can expect good outcome of stroke

Identification of Lys49-PLA2 from crude venom of Crotalus atrox as a human neutrophil-calcium modulating protein

We fortuitously observed a human neutrophil intracellular free-calcium concentration ([Ca2+]i) increasing activity in the commercially available phosphodiesterase I (PDE I), which is actually dried crude venom of Crotalus atrox. As this activity was not observed with another commercially available pure PDE I, we tried to find out the causative molecule(s) present in 'crude' PDE, and identified Lys49-phospholipase A2 (Lys49-PLA2 or K49-PLA2), a catalytically inactive protein which belongs to the phospholipase A2 family, by activity-driven three HPLC (reverse phase, size exclusion, reverse phase) steps followed by SDS-PAGE and LC-MS/MS. K49-PLA2 induced Ca2+ infl ux in human neutrophils without any cytotoxic eff ect. Two calcium channel inhibitors, 2-aminoetoxydiphenyl borate (2-APB) (30 microM) and SKF-96365 (20 microM) signifi cantly inhibited K49-PLA2-induced [Ca2+]i increase. These results suggest that K49-PLA2 modulates [Ca2+]i in human neutrophils via 2-APB- and SKF-96365-sensitive calcium channels without causing membrane disruption.

Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Scant Extracellular NAD Cleaving Activity of Human Neutrophils is Down-Regulated by fMLP via FPRL1

Extracellular nicotinamide adenine dinucleotide (NAD) cleaving activity of a particular cell type determines the rate of the degradation of extracellular NAD with formation of metabolites in the vicinity of the plasma membrane, which has important physiological consequences. It is yet to be elucidated whether intact human neutrophils have any extracellular NAD cleaving activity. In this study, with a simple fluorometric assay utilizing 1,N6-ethenoadenine dinucleotide (etheno-NAD) as the substrate, we have shown that intact peripheral human neutrophils have scant extracellular etheno-NAD cleaving activity, which is much less than that of mouse bone marrow neutrophils, mouse peripheral neutrophils, human monocytes and lymphocytes. With high performance liquid chromatography (HPLC), we have identified that ADP-ribose (ADPR) is the major extracellular metabolite of NAD degradation by intact human neutrophils. The scant extracellular etheno-NAD cleaving activity is decreased further by N-formyl-methionine-leucine-phenylalanine (fMLP), a chemoattractant for neutrophils. The fMLP-mediated decrease in the extracellular etheno-NAD cleaving activity is reversed by WRW4, a potent FPRL1 antagonist. These findings show that a much less extracellular etheno-NAD cleaving activity of intact human neutrophils compared to other immune cell types is down-regulated by fMLP via a low affinity fMLP receptor FPRL1.

Preparation and characterization of chloramphenicol niosomes and comparison with chloramphnicol eye drops [0.5%w/v] in experimental conjunctivitis in albino rabbits

Niosomes has gained tremendous popularity as ultimate drug carrier. Lot of research work is being carried out on preparation of niosomes for ophthalmic use having no significant effect on vision and its sustained release pattern. Chloramphenicol niosomes were prepared using two different ratios of cholesterol, drug and surfactant, termed as EIN-1, EIN-2 by ether injection method and their entrapment efficiency, particle size. The in vitro drug release pattern was observed for ten hours. The EIN-2 showed 90% entrapment and released 81% of entrapped drug after 10 hours. Zeta potential and viscosity were determined and in vivo comparison was made with Chloramphenicol eye drops where it exhibited Cmax of 15 microg/ml. Stability studies were done to determine shelf life. MIC of selected strain of S. aureus was also determined. EIN 2 niosomal suspension was compared with Chloramphenicol eye drops in experimental conjunctivitis in albino rabbits. In vitro studies are encouraging as niosomes released about 75% of total entrapped drug by EIN-1 and 81% of total entrapped drug by EIN-2. In vivo study shows that niosomes released the drug in eye in acceptable range and showed a sustained release pattern without affecting the vision. Niosomes were found ultimate ophthalmic drug carriers capable to release drug in sustained and determined pattern

child with roberts syndrome

Roberts syndrome Is a genetically determined rare birth defect causing, skeletal deformities, particularly symmetrical limb reduction and craniofacial anomalies. For any child with limb and craniofacial bony malformations, this syndrome should be considered in the differentials. Although this syndrome represents only a small proportion of the total number of individuals with limb deficiency, it is important to be identified in order to give accurate genetic counselling including recurrence risk in siblings and possible prenatal diagnosis. This is the case report of a 22 days old male infant who presented with defective development of all four extremities and craniofacial abnormalities. The overall clinical and radiological features were suggestive of Roberts syndrome

Neurofibromatosis type II: a rare neurocutaneous syndrome

Neurocutaneous syndromes are heterogeneous group of disorders with abnormalities of central as well as peripheral nervous system. Neurofibromatosis type II [NF-II] is an autosomal dominant neurocutaneous syndrome rarely diagnosed in pediatric population. Diagnosis is based on clinical history and radioimmaging. We present a 14 years old boy with headache and decreased hearing, who turned to be a case of neurofibromatosis type II

Short term Neurodevelopmental outcome of asphyxiated newborns at tertiary care unit

To find out the short term neurodevelopmental outcome of asphyxiated newborns. Cross-sectional study using prospective data. Neonatal unit of Children's Hospital, Lahore from August, 2000 to July, 2001. We included 150 cases of birth asphyxia and survivors were followed till the age of six months and neurodevelopmental status was assessed by Denver developmental screening test II [DDST-II]. Severity of asphyxia was categorized as no encephalopathy, three different stages of HIE. During follow up visits, normal to delayed developmental status was expected. Infants were divided into two groups. Group A included neonates without HIE and group B with encephlopathy. Among group B, newborns developmental delay was found in 9 neonates and 48 neonates died while in group A neonates there was no child who had developmental delay and only six newborns died.[P value<0.05] There were 117 [78%] males, 35 mothers [23%] had antenatal visits to trained medical professionals. Majority of mothers [76%] had their visits to non doctor personnel like midwives, lady health visitors or nurse. Majority [61%] of study population were home delivered, 24% at private clinics and maternity homes while only 14% came from hospitals. Different stages of HIE have strong correlation with the outcome of these neonates. More effort and resources should be directed to this preventable community problem

Diagnostic role of EEG in children having unprovoked seizures, experience at the neurophysiology department, The children's hospital, Lahore

Although advances in imaging technology offer ever-increasing diagnostic accuracy, the electroencephalogram [EEG] retains its importance and is the cornerstone for the diagnosis and treatment of epilepsy. A cross-sectional descriptive study was conducted at Neurophysiology Department of The Children's Hospital, Lahore. Our aims were to find out the different types of epilepsies diagnosed on EEG in children referred for interictal EEG with recent clinical diagnosis of epilepsy. Out of 645 children referred for EEG after seizures, 415 [64%] were males and 230 [36%] were females, 21% had their first seizure before one year of age, 54% of them were between the ages of 1-5 years and 46% of them were more than 5 years of age. We found normal interictal EEGs in 54% whereas 46% children had abnormal EEGs. So in addition to supporting the diagnosis of epilepsy, EEG has significant potential to classify epileptic seizures

Early predictors of intractable epilepsy in children: a case control study

Case control, Hospital based. Site: Epilepsy Centre, The Children's Hospital, Lahore-Pakistan. From 1st Sept 05 to 30th Nov 06 Knowing the prognosis of epilepsy in children would undoubtly influence the treatment strategy. All the children, age 1 year to 16 years receiving anti-epileptic drugs for their idiopathic or cryptogenic epilepsy were the study population. After six months of commencement of treatment various factors associated with well control the ["controls"] and intractability the ["cases"] were analyzed and a univariate comparison was done between various factors for these two groups. Over a period of 14 months, 520 children, 33% the "control" and 67% the "cases" among these patients were enrolled for this study. Statistically, male gender history of birth asphyxia, initial seizure type, past head trauma, previous CNS infection and family history of epilepsy are not the risk factors, whereas seizures starting in infancy, seizures episodes >10 before commencing treatment, neonatal seizures and neurological deficit present at presentation were the risk factors for intractable epilepsy. Myoclonic seizures, status epilepticus before starting treatment and infantile spasm were seen in the "case" group only. We conclude children having risk factors for intractable epilepsy have poor prognosis and recommend that such children should be referred to epilepsy centre as soon as possible

Intrathecal isobaric versus hyperbaric bupivacaine for elective Caesarean section

To compare the results of isobaric bupivacaine [0.5%] with hyperbaric bupivacaine [0.75%] in cases of elective Caesarean Section, in respect of time to sensory analgesia, highest level of sensory block, haemodynamic effects, and complications. Interventional, experimental study from March 2003 to March 2004. Department of Anaesthesiology and Surgical Intensive Care Unit, Dow University of Health Sciences and Civil Hospital, Karachi. Sixty pregnant patients scheduled for elective Caesarean Section. The patients were randomly assigned to receive either 0.5% isobaric bupivacaine [Group-1B] or 0.75% hyperbaric bupivacaine [Group-HB] via intrathecal route. The time of onset of block, highest level of sensory block, cardio-respiratory data, duration of analgesia and complications were recorded during surgery. Results: The time taken to reach T4 sensory analgesia in Group-IB was 6 +/- 6.43 minutes as compared to 6.93 +/- .7.8 minutes in Group-HB, while the highest sensory level achieved in Group-IB was TI and in Group-HB T2. The lowest systolic blood pressure recorded in Group-IB was 83.27 +/- 12.69 mmHg and in Group-HB 114.33 + 13.83 mm Hg, the difference being significant [p < 0.05]. There was a higher incidence of complications in Group-IB as compared to Group-HB like high spinal analgesia, vomiting and discomfort. Intrathecal block showed a greater reduction in the systolic blood pressure, and associated complications, with Isobaric Bupivacaine as compared to Hyperbaric Bupivacaine

Tranverse myelitis: Unusual site of involvement

Transverse myelitis is defined as an acute inflammation of spinal cord leading to abrupt onset of weakness of lower limb. In majority of cases, mid thoracic spine is involved. We present a ten year old girl whose cervical spinal cord was involved which is rare. MRI of spine is the investigation of choice

Myotonia congenita in a brother and sister

Myotonia congenita is a rare channelopathy and carries a good prognosis. Two cases of young siblings are presented detected with difficulty in gait and motor activities. Both had typical hypertrophied body musculature. EMG was diagnostic

Post operative throat complications after general anesthesia, a comparison between laryngeal mask airway and endotracheal tube

To determine the incidence of post operative throat complications such as pain dvsphagia, hoarseness of voice, dryness of throat and cough, after general anesthesia, and to compare between laryngeal mask airway and endotracheal tube. Prospective, double blinded, comparative, randomized observational study. Department of Anesthesiology and Surgical Intensive Care Unit, Civil Hospital Karachi, over a period of one year. 150 randomly selected A.S.A I and A.S.A II patients receiving general anesthesia were divided into two groups, 75 patients in each group. One group receiving general anesthesia through endotracheal tube and other group through laryngeal mask airway. This study was based on two proformas 1. Intra operative proforma. 2. Post operative proforma. This study has shown that the incidence of post operative throat complications after general anesthesia are 51/150 [34%] i.e 35/75 [46.6%] with endotracheal tube and 16/75 [21.3%] with laryngeal mask airway. General Anesthesia with laryngeal mask airway is associated with lesser number of throat complications as compared to endotracheal tube