Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours / 대한뇌졸중학회지

Background@#and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). @*Methods@#This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). @*Results@#Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0–2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence. @*Conclusion@#In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients’ age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.

Gastric emptying scintigraphy in postprandial distress syndrome

Objective: To find out the pattern of gastric emptying scintigraphy [GES] in patients with post prandial distress syndrome [PDS]

Methods: This study was carried out from January 2015 to July 2016 at Combined Military Hospital [CMH] Kharian and Nuclear Medical Centre [NMC] of Armed Forces Institute of Pathology [AFIP] Rawalpindi. Patient's inclusion criteria were dyspepsia of post prandial distress type for more than six months duration. Patients with dyspepsia due to epigastric pain syndrome and other organic disorder were excluded. Upper gastrointestinal endoscopy was performed in all patients to rules out organic causes. Four-hour Gastric emptying scintigraphy was carried out at NMC, AFIP. Results were compiled and statistical assessment was done by utilizing SPSS IBM 22 version

Results: Thirty-eight patients were included in the study with age range from 15-72 years with mean age of 37.05 +/- 13.5 years. Males were 28[73.7%] and 10[26.7%] were female. Mean gastric retention with SD at one, two, three and four hours were 63 +/- 19.04, 37 +/- 20.62, 19 +/- 16.66 and 10 +/- 12.73 percent respectively. Early gastric emptying was in 3[7.89%] and delayed gastric emptying at two and four hours was seen in 4[10.52%] and 12[32%] respectively. Seventeen [44%] of the patients had normal gastric emptying despite the classical symptoms of PDS

Conclusion: Gastric dysmotility in GES seen in half of the patients points some additional mechanism as well like gastric accommodation or visceral hypersensitivity in the patients with PDS

Endoscopic findings in non ulcer dyspepsia; a new perspective

Objective: To see the pattern of endoscopic findings in patients with non-ulcer dyspepsia. Study Design: Observational cross sectional study. Place and Duration of Study: Department of Gastroenterology, Combined Military Hospital Kharian Pakistan, from Jan 2015 to Dec 2015

Material and Methods: Two hundred and seventy seven patients were included in the study. Patients presenting with dyspeptic symptoms at outpatient Gastroenterology Department were included in this study. Upper GI endoscopy was carried out and those having ulcers or any structural lesion were excluded from the study. Endoscopic findings were interpreted with IBM SPSS version 22

Results: Out of 277 patients, 146 were male and 131 female. Their minimum age was 12 and maximum age was 86 years with 44 +/- 15.5 [mean +/- SD]. Maximum numbers of patients were between ages of 31 to 50 years. Endoscopy was normal in 112 [40.4%] patients, showed mild gastritis in 118 [43.7%], moderate gastritis in 17 [6.1%], duodenitis in 19 [6.9%], and mixed findings in 8 [2.9%] patients. Bile was present in 144 [52%] and absent in 133 [48%] of the endoscopies

Conclusion: Mostly patients have either normal findings or mild gastritis on upper GI endoscopy. Gastric bile reflux was a common observation

Post esophageal variceal band ligation pain, another insult to injury

Objective: To measure and characterize pain in post esophageal variceal band ligation patients

Study Design: Cross sectional observational study

Place and Duration of Study: This study was carried out in Combined Military Hospital Kharian which is a tertiary care hospital, from Dec 2014 to Aug 2015

Material and Methods: All patients of esophageal varices due to any underlying pathology requiring esophageal variceal band ligation [EVBL] were included in this study. Patients unwilling for EVBL were excluded from the study

Their EVBL was done with the help of Upper Gastrointestinal Pentax High definition 90i series Video Endoscope and subsequently they were inquired about the details of pain till next session of banding

Results: Out of 86 patients 63 [73%] were males and 23 [27%] were females. Their mean age was 54 years with SD +/- 12. Pain was present in 47 [54%] patients and 39 [46%] were pain free. It was severe in 3 [7%], moderate in 34 [72%] and mild in 10 [21%] patients. Out of post EVBL pain group 30 [65%] patients experienced pain after first EVBL session, 12 [25%] in subsequent and 5 [10%] after all the sessions

Conclusion: Post EVBL pain is a common complication. Mostly it is mild to moderate in intensity and needs attention in almost half of the patients to relief the suffering

Sucralfate and Lidocain: Antacid 50:50 solution in post esophageal variceal band ligation pain

Objective: To compare the effectiveness of pain relief of Sucralfate and lidocain: antacid 50:50 solution in post esophageal variceal band ligation pain

Methods: All patients who had under gone Esophageal Variceal Band Ligation [EVBL] were included in the study. Patients un-willing to be included in the study or those who didn't have post EVBL pain were excluded. Patients with post EVBL pains were divided into two groups: one group was given sucralfate and other was given lidocaine: antacid 50:50 solution. Both were inquired about the duration of the pain relief after the medication. The results were analyzed on SPSS 23. Independent samples T-test was performed to find out whether the difference in duration of pain relief was significantly different in the two groups

Results: Out of 110 patients who have EVBL, 66[60.00%] had pain and 44[40.00%] were pain free. In the pain group 46 [69.7%] were given sucralfate and 20 [30.3%] were given lidocain: antacid 50:50 solution. Mean duration of pain relief in two groups was 2.78 [SD +/- 2.096] and 2.5 days [SD +/- 0.76] respectively. Independent samples T-test results revealed that there was no statistically significant difference in the duration of pain relief between these two groups with p value 0.426

Conclusion: Both Sucralfate and Lidocain: antacid 50:50 solutions are effective in relieving the post EVBL pain. However, no statistically significant difference in duration of pain relief was detected in separate groups of patients treated with either treatment

Hepatitis B leading to megaloblastic anemia and catastrophic peripheral thrombocytopenia

Hepatitis B virus [HBV] typically causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. It is associated with a variety of extrahepatic complications. We herein, present a rare extrahepatic complication of HBV infection. A 32-year man presented with melena, bleeding from gums and fever. Peripheral blood examination revealed anemia, macrocytosis and severe thrombocytopenia. His hepatitis B surface antigen [HBsAg] was positive but deoxyribonucleic acid [HBV DNA] by polymerase chain reaction [PCR] was negative. Other hepatitis, human immune deficiency virus [HIV], dengue, and autoimmune serology were negative. Bone marrow examination revealed megaloblastic erythropoiesis. There was mild to moderate reduction of megakaryocytes in bone marrow, which was not compatible with severe peripheral thrombocytopenia. His response to cyanocobalamin and folic acid was remarkable for myeloid cell lines and moderate for erythroid cell lines, but poor to platelet counts. Platelet counts gradually improved to safe limits with eltrombopag, likely reflecting autoimmune pathogenesis for thrombocytopenia. This case report highlights multiple targets of HBV infection with associated multiple pathogenetic mechanisms

Histopathological analysis of gastric mucosal biopsies in non ulcer dyspepsia

Objective: To find out the pattern of gastric mucosal histopathological findings in gastric biopsies of patients with non ulcer dyspepsia

Study Design: Prospective descriptive study

Place and Duration of Study: Histopathology department Combined Military Hospital [CMH] Kharian Pakistan from Jan to Dec 2015

Material and Methods: One hundred patients presenting at outpatient gastroenterology department with dyspepsia having no endoscopic lesion were included in the study. Two gastric mucosal biopsies from antrum and two from corpus were taken. The specimens were processed and examined histologically to see the changes

Results: Gastric biopsies of 100 patients including 65 males and 35 females presenting with non ulcer dyspepsia were studied. Most of the patients were between the age group of 31-50 years. Histological examination of gastric biopsies revealed 70% of patients having histological features of gastritis, while 30% having no significant histological finding. Chronic inflammation was seen in 70 cases [70%], activity in 15 cases [15%], glandular atrophy in 2 cases [2%] and intestinal metaplasia in 2 cases [2%]. H.Pylori were identified in 25 cases [25%] based on haematoxylin and eosin [H and E] staining and modified giemsa staining

Conclusion: Most the cases of non ulcer dyspepsia show histological evidence of gastritis, however a significant number of patients showed no gastric mucosal histological abnormality. A significantly low frequency of H. Pylori in gastric biopsies noted in non ulcer dyspepsia cases may be due to more frequent use of antibiotics and acid suppressant drugs used by general practitioners at some stage of disease

Ruptured Hydatid cyst in biliary tract

A lady aged 26 years reported with a 2 months history of fever, upper abdominal pain and weight loss. Her abdominal ultrasonographic scan revealed a complex cystic mass in left lobe of liver suggestive of hydatid cyst that was confirmed on magnetic resonance imaging of abdomen and magnetic resonance cholangiopancreatogram. With strong suspicion of a hydatid cyst, endoscopic retrograde cholangiogram was performed which confirmed the diagnosis. During the procedure, hydatid membranes protruding from the papilla were removed after sphincterotomy. She was put on albendazole 400 mg twice daily after the procedure and showed a remarkable clinical improvement

Foreign body nose in children presenting at a tertiary care teaching hospital in Pakistan

To determine the patient management factors and patient outcomes in pediatric patients of foreign bodies in nose. This descriptive study was performed in ENT Department, Khyber Teaching Hospital, Peshawar from February, 2006 to January, 2007. Two hundred fifty seven cases of foreign bodies in nose in patients upto 12 years of age were included. Personal data, clinical features, investigations, management details and complications were recorded on a pre-designed proforma. In younger non cooperative cases foreign bodies were removed under general anesthesia, while in cooperative children it was removed without anesthesia by using suction, use of forceps and foreign body hook. Among 257 cases of foreign bodies in nose 48.46% were between 4 to 8 years, with male preponderance i.e. 63%. Unilateral and bilateral presentations were seen in 95% and 5% cases respectively. Most common foreign body types were plastic beads, pearls, pieces of sponge and small round objects. There were two cases of alkaline battery lodged in the nose. General anesthesia had high success rate. Round shape foreign bodies and younger children are associated with poor outcome with removal attempts made under direct visualization. These cases should be referred directly to otolaryngologists for removal under general anesthesia

Otorhinolaryngological manifestations of tuberculosis

Tuberculosis, one of the oldest disease in man, is even today, a leading cause of human suffering and loss of life. TB has the potential to infect any organ in the body due to lympho-haematogenous dissemination. Therefore, this study was conducted to know the manifestations of the disease in various regions of Otolaryngology. The study was conducted in the ENT department, Khyber Teaching Hospital, Peshawar. Duration of study was two years from January, 2005 to December, 2006. A total of 100 patients presented with primary head and neck TB during the study period. Most of these [97%] had tubercules cervical lymphadenpthy. Age ranged from 8 to 55 years. The mean age was 31.5 years. Thirty six were male and 64 were female. Sixty five patients were diagnosed by FNAC examination and 32 required biopsy and histopathological confirmation. One patient each of laryngeal TB, cervical spine TB and retropharyngeal abscess [TB] were diagnosed by MRI. TB is a challenging disease, its diagnosis requires a high index of suspicion. FNAC is a reliable and easy way to diagnose, however, gold standard is biopsy for histopathology

Endoscopic management of common bile duct stones experience at military hospital, Rawalpindi

To determine the characteristics of patients presenting with common bile duct [CBD] stones, to know the type of endoscopic therapy employed and to see procedure related complications. A descriptive study Palace and Duration of Study: The study was conducted in the Department of Gastroenterology of Military Hospital, Rawalpindi from Jan 2007 to Dec 2007. Adult patients with common bile duct stones who underwent endoscopic retrograde cholangiopancreatography [ERCP] enrolled in a consecutive manner. The procedure was done under sedation with midazolam and meperidine after informed and written consent. Patients data was obtained from the department and entered on a spread sheet to calculate percentages and frequencies .The data was analyzed using Statistical Package for Social Sciences [SPSS] version 10 to document the endoscopic procedures done and the procedure- related complications. Two hundred and twenty five patients underwent ERCP for evaluation and treatment of CBD stones. Mean age was 45 years with female to male ratio of 1.9: 1. Out of 225 patients, cannulation failed in 4 cases due to duodenal stenosis and 154 [70%] out of 221 cases of CBD stones mandated endoscopic treatment with balloon trail, basket extraction, placement of plastic biliary stent temporarily or use of mechanical lithotriptor. Duct clearance was achieved in 67% cases. Complication rate has been 9% with bleeding being the most common complication with no mortality. A duct clearance rate of over 67% was achieved with sphincterotomy combined with balloon trail, basket extraction and lithotripsy. Bleeding was the most common procedure- related complication. Very large CBD stones/ Mirrizi syndrome cases were referred for surgical intervention

Her 2 neu metflstatic breast cancer; low dose sequential docetaxel - capecitabine chemotherapy as first line treatment a clinical trial of cancer research group Pakistan

To evaluate the efficacy and toxicity of low dose sequential docetaxel-capecitabine chemotherapy as first line treatment of HER 2 negative metastatic breast cancer [MBC]. Experimental Study, Clinical Trial. Three different oncology centers, collaborating under the Cancer Research Group Pakistan. From June 2006 to December 2007. Female breast cancer patients with visceral or visceral and bone metastases and a KPS > 70 were eligible. Results: 38 patients were enrolled. Median age was 49 years [Range 32-70]. With docetaxel treatment, CR was seen in 06 [16%] patients and PR in 20 [53%] with an overall response rate of 69%. Stable disease was seen in 10 [26%] and PD in 02 [05%]. Four out of six complete responses were in patients with liver metastases. Thirty six patients received capecitabine. Thirty were evaluable for response. Capecitabine added one CR [3.33%] and six partial responses [20%]. Two patients [6.67%] who had a partial response to docetaxel relapsed during capecitabine treatment. As a result at the completion of the therapy CR was seen in 07 patients [18.42%], PR in 23 patients [60.53%] with SD and PD in, 4 patients [10.53%] each. An overall RR of 78.94% was seen. Median time to progression was 10.9 months [range, 3-22 months] and at a median follow up time of 24 months [range, 16 -34 months] 13 patients have died with an overall survival probability of docetaxel -capecitabine sequential therapy of 0.68. Significant docetaxel specific grade 3/4 toxicities included neutropenia and diarrhea in 14 [36.84%] and 03 [07.89%] respectively. Febrile neutropenia was seen in 06 [15.79%]. Capecitabine specific significant grade 3 toxicities included hand-foot syndrome in three patients [8.33%] and diarrhea in 2 [5.56%]. Stomatitis, dermatitis, fatigue was seen in one patient [2.78%] each. This treatment schedule of low dose sequential docetaxel - capecitabine is an effective first line treatment of HER 2 negative MBC that provides good overall response rate, manageable toxicity and improved survival

Indications for endoscopic ultrasound and diagnosis on fine needle aspiration and cytology

To determine common indications for requesting Endoscopic Ultrasound [EUS] and to describe the diagnosis made after endoscopic ultrasound/Fine-Needle Aspiration and Cytology [FNAC] during two years at a tertiary gastrointestinal unit. Cross-sectional descriptive study. The study was carried out in Gastrointestinal Department of Military Hospital, Rawalpindi, from March 2006 to February 2008. One hundred and eighty nine patients who underwent EUS during study period at Military Hospital were included in the study. Patients too ill [hypoxemic/hypotensive] to undergo procedure safely and those with complete esophageal blockage at upper end by tumour not allowing scope/EUS probe to advance beyond were excluded. EUS was done with Olympus Exera EUS 160, linear or radial scope, as required. EUS findings were recorded against indications as enlarged lymph nodes, tumour, staging, normal or incomplete. Fine-Needle Aspiration [FNA] was done as per findings on EUS using 21-22 G needle. An on-site cytopathologist made the provisional cytopathological diagnosis. Final cytology/histopathology report was given after review of slides by consultant histopathologists at Armed Forces Institute of Pathology [AFIP], Rawalpindi, and were documented as tuberculosis, malignancy, chronic pancreatitis or reactive hyperplasia. Data was analyzed for documentation of patients' age, gender, common indications, findings on EUS/FNAC, using SPSS version 10. Percentages and frequencies were calculated for the presence of these above-mentioned variables. Of the 189 patients, 145 [77%] were male and 44 [23%] female. Age was 18-80 years [mean 49 years]. Major indications for referral were lymphadenopathy in 92 [49%], suspected growth pancreas in 57 [28%], growth of stomach in 20 [11%] and a heterogeneous group included esophageal, liver, retroperitoneal masses, rectal and other pathologies. Findings on EUS included lymphadenopathy in 76, mostly in sub-carina and AP window. Mass in pancreas was seen in 36, followed by stomach tumour in 17 and esophagus in 9. FNAC was done in 142 out of 189 patients. Final diagnosis out of 67 FNAC/histopathology of lymph nodes were tuberculosis in 26 and malignant lesions in 23. These included metastatic adenocarcinoma in 8, lymphoproliferative disorder in 7, metastatic squamous cell carcinoma in 5, small cell carcinoma in 2 and anaplastic in 1. Pancreatic tumours were adenocarcinoma in 16, poorly differentiated in 3 and neuroendocrine in 2. Stomach tumours were found in 11, and included lymphomas 5, GIST 3, carcinoids 2, metastatic choriocarcinoma 1 and adenocarcinoma in 1. Therapeutically, 3 celiac blocks and one pancreatic pseudocyst drainage was done. The main indication of EUS and pathology of mediastinal and celiac nodes were metastatic malignancy and tuberculosis. Pancreatic adenocarcinoma was another common cause for asking EUS

Prevalence of blood pressure and blood sugar in a sample of older people: a situation analysis across different socio-economic neighborhoods in Lahore, Pakistan

The blood pressure and blood sugar levels were measured from a sub-sample of older persons of both sexes across six urban localities of Lahore, Punjab, Pakistan. A survey was conducted on 921 respondents in September 2006 to accomplish our PhD research; 300 respondents aged 50 years and above were tested for blood pressure and blood sugar levels. Systolic and diastolic blood pressures increased with age, as expected, while diabetes was more prevalent in younger cohort of respondents. Exactly 17.6% of the total number of respondents were suffering from hypertension stage-2 [SBP> 160/DBP> 100 mmHg] and 21.0% of them had> 180 mg/dL sugar level. Gender based comparison indicated that women suffered more from hypertension and diabetes than their male counterparts. Both the hypertension and diabetes were more prevalent among the respondents from lower socio-economic strata. These findings are expected to underline the need for the due policy interventions for improving the life quality of our elderly