Vulnerable road users are at greater risk during Ramadan - results from road traffic surveillance data

To assess how the frequency, nature and outcome of road traffic crashes differ during the fasting month of Ramadan. The retrospective study was conducted in Karachi and comprised data from the Road Traffic Injury Surveillance Project which entailed information on all road traffic injury victims presenting to Emergency Departments in the city between September 2006 and September 2011. Data was analysed to find the frequency of road traffic crashes according to time of incident, road user group and survival. Ramadan and Non-Ramadan groups were compared with respect to time and frequency of incidents, road user group and mortality. SPSS 16 was used for statistical analysis. There were 163,022 subjects from whom 13,640[8.36%] came during Ramadan and 149,382 [91.6%] during the non-Ramadan months. Frequency of road traffic crashes did not change significantly during Ramadan, but was clustered around the breaking of Fast and the Taravih prayers. The most commonly affected road user group was motorbike riders followed by pedestrians. Overall survival of the RTI victims was 96.1% with a mortality rate of 4.1% which was higher than the figure of 3.5% in the non-Ramadan period. Vulnerable road users were more frequently involved in road traffic injuries during Ramadan. Moreover, the frequency of crashes increased around evening which requires more careful planning of traffic controls, especially for the vulnerable road users

Political determinants of Health: Lessons for Pakistan

There is much concern about the capacity of the health system of Pakistan to meet its goals and obligations. Historically, the political thrust has been absent from the health policy formulation and this is reflected in the low and stagnant public allocations to health. Successive political leaderships have averred from considering healthcare is a common good rather than a market commodity and health has not been recognized as a constitutional right. Over 120 of world's nation states have accepted health as a constitutional right but the 1973 Constitution of Pakistan does not mandate health or education as a fundamental right and the recently adopted 18th constitutional amendment missed the opportunity to extend access to primary health care as an obligation of the State. It is argued in this communication that missing from the calculations of policy formulation and agenda setting is the political benefits of providing health and other social services to underserved populations. Across the developing world, many examples are presented of governments undertaking progressive health reforms that bring services where none existed and subsequently reaping electoral benefit. The political determinant of healthcare will be realized when the political leaders of poorly performing countries can be convinced that embracing distributive policies and successfully bringing healthcare to the poor can be major factors in their re-elections

Polio travel restrictions: a sledgehammer to crack a nut?

Imposition by WHO of mandatory vaccination for international travelers from Pakistan has caused confusion and panic amongst travelers besides the adverse effect on the country's image from the widely reported statement. It is felt that the announced measure is not primarily supported by science but is rather a response to disillusionment in the donors about the repeatedly missed eradication targets set by WHO. In the past few years, exportation of poliovirus from Pakistan has caused outbreaks in China, Iraq and Syria besides the ongoing two way transmission with Afghanistan, but the carriers in these spreads are mainly land route travelers. Vaccinating all air travelers is unnecessarily punitive besides being probably ineffectual in halting exportation.The unrelenting focus on polio eradication may have negative impact on fragile health systems besides arousing suspicions of religious elements opposed to vaccination. Routine vaccination and polio campaigns as part of community development measures such as provision of clean drinking water and elimination of surface sewage drainage would be more accepted. The government would be well advised to assume control of the polio eradication program and make it a national development issue

Management of myelomeningocele

T To find out best possible protocol to provide productive life to children born with Myelomeningocele. Descriptive study. Department of Neurosurgery, Jinnah Postgraduate Medical Centre Karachi from December 2001 to December 2006. The medical record of 415 children with myelomeningocele operated at our center was reviewed retrospectively. The surgical and medical management protocol used for different sites of myelomeningocele was studied.The age of most of the patients at the time of myelomeningocele repair was between 25-30 days; however, children with ruptured myelomeningocele were consistently repaired early. All paraplegic patients with dorsolumbar myelomeningocele were treated with either a low-pressure ventriculoperitoneal [VP] shunt only, direct repair or both. Patients with cervical, dorsal and lumbo-sacral myelomeningocele requiring VP shunt were operated either simultaneously for both procedures or with delayed insertions of a VP shunt after treatment of ventriculitis All 16 patients with ruptured myelomeningocele [3.8%] were treated for repair as well as ventriculitis. Complications including CSF leak, wound infection or necrosis after repair of myelomeningocele occurred in 22 cases [5.3%]. The postoperative follow up for all patients was 1- 2 years Surgical intervention with a low-pressure VP shunt in large dorsolumbar myelomeningocele produced good results

Surgical management of tethered spinal cord syndrome: an analysis of 248 cases

To define the presentation, exact mechanism, and surgical treatment of tethered spinal cord syndrome [TSCS] with particular emphasis on timing of surgery and outcome. Department of Neurosurgery, Jinnah Postgraduate Medical Centre [JPMC] from January 2001 to December 2006. A total of 248 patients were included in this study who presented for treatment between 6 days and 32 years of age with a median age of 6.5 months. One hundred patients presented before the age of 6 months. Most common complaint was cosmetic defect/swelling on their back [n 156]. Sixty-six patients had urinary incontinence, 35 patients had deformed or weak leg and 15 had ulcers on their feet. There were 172 female and 76 male patients. The most frequent tethering lesions were lipoma in 156, un-repaired myelomeningocele in 15, post repair myelomeningocele in 18, hypertrichosis in 17, spilt cord malformation in 10, tight filum terminate in 15, dermal sinus or dimple with stalk in 12, sacral agenesis in 3 and appendage with stalk in 2 patients. Out of 100 operated before 6 months of age, only 2 patients returned back with incontinence of urine and required un-tethering again. Improvement of symptoms at 6 months after surgery was noted in 78% patients operated after 6 months of age. Stabilization of symptoms was achieved in 8 patients having adult age at time of surgery. Minimum follow up was two years in 210 and maximum of 4 years in 17 surgically treated patients with stable neurological condition. Best outcome is achieved after complete un-tethering of cord at younger age. To avoid irreversible neurological damage, early diagnosis and repair is recommended. The symptoms most resistant to surgical treatment were orthopedic abnormalities where as bladder dysfunction and motor weaknesses were amendable to surgical therapy

Trans-mastoid approach to otogenic brain abscess

The treatment of otogenic brain abscess initially involves excision or aspiration of the abscess through a temporal or sub-occipital route depending on its location. This is followed by a mastoidectomy by the ENT surgeon to eradicate the primary source of infection. During the last three years, we have approached such lesions through a mastoidectomy followed by excision of the abscess through the same approach. This trans-mastoid approach is technically feasible in following the tract of suppuration, and clearing the cause and effect of pathology, at the same sitting. This paper describes our initial experience with the trans-mastoid approach to otogenic brain abscesses. On the basis of our results, we believe that transmastoid approach is an effective and logical option for the treatment of otogenic brain abscess, and merits further investigation in the form of a prospective study

Surgery for prolactinomas

A large proportion of prolactin secreting tumours of the pituitary gland are treatable by dopamine agonist drugs. However certain subgroups of these patients are better managed by surgical excision. The indications for surgery in prolactinomas remain controversial and this paper attempts to clarify these with illustrative cases. The factors favouring a surgical approach include poor tolerance of long term medical therapy, progression of visual deficits or recurrence while on medical treatment, cystic change in the tumour with pressure effects, CSF fistula secondary to tumour shrinkage and prophylactic surgery in tumours anticipated to cause CSF leak following medical therapy. The size and invasiveness of the tumour and the prolactin level are also important determinants of treatment planning. The indications for surgery in prolactinomas are discussed and illustrative cases are presented

Towards a cure for traumatic paraplegia - is there cause for hope?

In the past decade, great strides have been made in the field of CNS tissue repair and expectations have been raised that a cure of spinal paralysis is at hand. The two broad categories of investigational approaches to spinal regeneration are: [1] Enhancing the Regenerative Milieu of the Cord and [2] Cellular and Tissue Transplantation. Amongst the latter approaches, the early use of foetal cord tissue has given way to the more sophisticated studies on stem cell therapy and the implants of olfactory ensheating cells. These have engendered considerable public interest and are being offered as commercially available therapies in clinics round the world to desperate patients. The internet by allowing the dissemination of non-peer reviewed information of experimental interventions catalyses this process. Physicians must be informed of developments in this area to offer appropriate advice and counsel to their patients

Comparison of two surveys of head injured patients presenting during a calendar year to an Urban medical centre 32 years apart

To study the patients presenting with head injuries to a tertiary hospital in Karachi during the year 2003. During the calendar year 2003, a cross-sectional study was conducted of all patients presenting to the casualty department of Jinnah Postgraduate Medical Centre [JPMC] with head injury. Personal information was collected from the patient's attendants at presentation or later if the patient had been brought in by the emergency services as an unknown person. The circumstances of the injury were similarly established and the clinical features documented. During the year 2003, a total of 3008 patients reported to the emergency room of JPMC. Of these 67% were males and the majority of the reporting patients [48%] had suffered their head injury in falls from a height. However, when considering the seriously injured patients warranting admission to the neurosurgery unit, road traffic injuries predominated [54%] and the age distribution was weighed towards an older age group with 70% being above the age of 20 years and mainly in the economically active 4th decade of life. One hundred and fifty four patients died for a mortality rate of 5% in the entire series of 3008 patients and 25% of the 623 admitted patients. The experience of head injuries reporting to our centre in two calendar years, 33 years apart, suggests that this attention to the crisis of death and disability occurring on roads is necessary

Brain Abscess with cyanotic heart disease

Twenty-eight patients of congenital cyanotic heart disease associated with brain abscess, who underwent neurosurgical intervention over a period of 5 years from June 1995 to June 2000 were reviewed. The mean age was 6.32 +/- 3.2 years [range 3-14 years] with a male preponderance. Patients having the tetralogy of Fallot were 78.57 percent. Abscesses located supratentorially were 49.28 percent with 42.8 percent predominance in the frontal lobe. Eighteen out of 28 patients were polycythemic with a mean haemoglobin of 16.07 +/- 2.7gm percent while their arterial oxygen saturation varied between 64 percent-92 percent. Twenty one patients underwent CT guided burrhole aspiration, under anaesthetist monitored local anaesthesia, with a repeat aspiration in 12 while aspiration was followed by craniotomy and excision of abscess in seven. Seven underwent primary excision. Mortality in patients undergoing craniotomy for excision of abscess was 35.7 percent as compared to burrhole aspiration group of 14.2 percent with an over all mortality of 25 percent. Morbidity in patients who survived surgery and were discharged was 57.42 percent. We found burrhole aspiration under anaesthetist monitored local anaesthesia relatively simple, effective and well tolerated in this particular group of patients. The overall prognosis of brain abscess associated with congenital cyanotic heart disease is poor; therefore early recognition of symptoms of brain abscess becomes mandatory

Vertebral body resection for spinal tumours causing dural compression

The Surgical treatment of spinal tumours presenting with signs of neural compression has evolved over the years with a trend away from standard laminectomy to anterior approaches dictated by the direction of the compression. An improvement in the results of surgical decompression have been reported using the newer techniques. We report here our experience of a radical anteiror approach to vertebral body tumours in seven patients with primary and secondary lesions of the spine. The approach has been safe and produced gratifying palliation with a reduction of pain and resumption of ambulatory status in all