Transient headache and neurological deficits with cerebrospinal fluid lymphocytosis syndrome: A comprehensive systematic review of 93 patients from 57 studies.

BACKGROUND: Headache with neurologic deficits and cerebrospinal fluid lymphocytosis, previously also termed pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis, is a self-limiting syndrome characterized by moderate to severe headache associated with focal neurological deficits occurring in the context of lymphocytosis in the cerebrospinal fluid. As a consequence of its rarity, data regarding headache with neurologic deficits and cerebrospinal fluid lymphocytosis is sparse. Therefore, we conducted this review to analyze data related to 93 patients of headache with neurologic deficits and cerebrospinal fluid lymphocytosis, to characterize their demographics, clinical manifestations, investigations and treatment options. METHODS: We performed a systematic review of cases reported through PubMed and Google scholar database, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Keywords used were 'Headache with Neurologic Deficits and cerebrospinal fluid lymphocytosis', 'Headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome'. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool. RESULTS: We analyzed a total of 93 cases of headache with neurologic deficits and cerebrospinal fluid lymphocytosis with a mean age of 28.8 years at onset. Seventy patients (75.2%) were adults, while 23 (24.7%) belonged to the pediatric age group. Comparing these groups, mean age at onset was 32.5 years and 14.3 years, respectively. The average duration of follow-up was 11.08 months. Thirty percent of patients experienced relapsing episodes of headache with neurologic deficits and cerebrospinal fluid lymphocytosis symptoms. The most common type of headache reported was unilateral severe throbbing episodic headache. Other associated symptoms included sensory deficit (60%) and motor deficits (54.8%). The least common symptoms were nystagmus and agraphia, which were reported in one patient each. Antiviral agents were a common treatment option in the acute phase (n = 23 patients [23.6%]), while Flunarizine was the most commonly used agent in the chronic setting (n = 3 patients [3.2%]). While most of the patients had normal brain magnetic resonance imaging, 20 patients had magnetic resonance imaging abnormalities, including (but not limited to) non-specific white matter lesions (eight patients) and meningeal enhancement (six patients). The most common electroencephalographic findings included diffuse and focal slowing. The mean cerebrospinal fluid opening-pressure was 240.5 mmH2O. Cerebrospinal fluid protein was elevated in 59 (63.4%) patients, with a mean value of 114 mg/dL. Two patients in our cohort were found to have cerebrospinal fluid oligoclonal bands. CONCLUSION: Headache with neurologic deficits and cerebrospinal fluid lymphocytosis tends to affect young individuals with a slight male predominance. Unilateral severe throbbing episodic headache with associated hemi-paresthesia and hemiparesis were the most common symptoms based on our review. Elevated cerebrospinal fluid opening-pressure can be seen in headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome. Early recognition of the syndrome is paramount. Antivirals were found to be among the most widely used treatments in the acute setting. Magnetic resonance imaging of the brain is mostly normal. Diffuse and focal slowing were among the most common electroencephalographic findings. Cerebral flow abnormalities on perfusion scans are not uncommon in headache with neurologic deficits and cerebrospinal fluid lymphocytosis. Prospective studies with a larger sample size are needed to validate our findings and guide the clinical care of these patients.

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system.

BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.

Frequency of Venous Thromboembolism in Patients with Liver Cirrhosis.

Introduction The major hemostatic problem in cirrhotic patients is the increased risk of bleeding, but venous thromboembolism is also being reported as a noticeable feature of cirrhosis. Therefore, we conducted this study to determine the frequency of venous thromboembolism in patients with liver cirrhosis. Materials and methods This cross-sectional study took place at a major metropolitan hospital in Karachi for a period of six months. A total of 142 patients age 40 to 70 years, either gender and Child-Pugh class A to C liver cirrhosis for >3 months were enrolled in this study. The demographic features like age, gender, weight, height, body mass index (BMI), duration of symptoms, and Child-Pugh class were noted. The patients were examined for calf swelling, tenderness, and pitting edema. Venous thrombosis was diagnosed on ultrasound of the calf done by an experienced radiologist in patients having two or more than two of the above-stated findings. The mean and standard deviation were calculated for age, weight, height, body mass index (BMI), and duration of symptoms. The frequency and percentage were calculated for the range of age, gender, range of weight, range of height, range of BMI, range of duration of symptoms, Child-Pugh class, and venous thrombosis. Stratification was done of venous thrombosis with age, obesity, gender, Child-Pugh class, and duration of symptoms by applying the chi-square test and assuming p-value ≤0.05 as significant. Results The mean age of the study population was 60.73 ± 10.83 years and most patients, i.e., 95 (66.9%) were >60 years. There were 89 (62.7%) female and 53 (37.3%) male patients. The mean weight of the study population was 60.15 ± 5.11 kg and most patients, i.e., 81 (57%), weighed ≤60 kg. The mean height of the study population was 1.53 ± 0.59 m and most patients, i.e., 99 (69.7%) were ≤1.5 m. The mean BMI of the study population was 27.24 ± 5.02 kg/m2 and most patients, i.e., 81 (57%) were ≤30 kg/m2. The mean duration of symptoms of the patients was 5.63 ± 1.77 months and most patients, i.e., 86 (60.6%) had ≤6 months of duration of symptoms. Eighty-six (60.56%) patients had Child-Pugh class A, 39 (27.47%) patients had Child-Pugh class B, and 17 (11.97%) patients had Child-Pugh class C liver cirrhosis. Ten (7%) of the patients had venous thrombosis. Stratification of venous thrombosis with age, gender, obesity, Child-Pugh class, and duration of symptoms showed a significant linear relationship with gender (p-value= 0.040), obesity (p-value= 0.043), and Child-Pugh class (p-value= 0.001). Conclusions Venous thromboembolism is a frequent complication and a pathogenic factor in liver cirrhosis that should be given attention to in cirrhotic patients especially in male and obese patients of Child-Pugh class B and C. Low serum albumin and increased partial thromboplastin time (PTT) can have some role in its prediction and early prevention. But more studies are needed to establish this.

Paraphenylenediamine (Kala Pathar) Poisoning at the National Poison Control Center in Karachi: A Prospective Study.

Introduction Suicide by self-poisoning is a common cause of death, especially in the younger population. More specifically, hair-dye poisoning is being increasingly used for suicide. Paraphenylenediamine (PPD), also known as "Kala pathar", is a highly toxic ingredient present in hair-dye that can cause death. Therefore, this study is designed to assess the demographics, clinical features, laboratory findings, and outcomes of PPD poisoning in patients admitted to the National Poison Control Center in Karachi, Pakistan. Materials and methods We conducted a prospective study for a period of six months at the National Poison Control Center, Karachi, Pakistan. A total of eight patients with PPD poisoning with no cardiac, liver, or renal co-morbidities were included in this study. The demographic characteristics, clinical features, laboratory findings, mode of intoxication, and route of intoxication were noted in a proforma. Furthermore, hospitalization time, tracheostomy status, mechanical ventilation status, and mortality rates were also recorded. For continuous variables, the means and SDs were calculated. Whereas for categorical data, percentages were calculated. Results In our study, the mean age of the patients was estimated at 25.38 ± 3.77 years. It was deemed that the majority of poisoning cases were intentional in nature (75%). These suicide cases were more commonly observed in young females (75%) who belonged to a low socioeconomic class (87.5%). The preferred route of administration was oral (87.5%). In 87.5% of the patients, the characteristic clinical features such as cervicofacial edema, dysphagia, dysphonia, and stridor were noted. During the later clinical stages of poisoning, clinical features such as rhabdomyolysis (62.5%), chocolate-colored urine (87.5%), hepatitis (75%), and acute renal failure (12.5%) were noteworthy. The mean ± SD of total leukocyte count (TLC), creatine phosphokinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum creatinine and serum potassium were, respectively, noted at 10,500 ± 3,854.4 cells/mm3, 32.87 ± 11.36 IU/L, 1,239.1 ± 1,106.2 IU/L, 776.8 ± 1,149.8 IU/L, 2.125 ± 2.275 mg/dL, and 4.9 ± 1.094 mmol/L. In our patients, the mean intensive care unit stay was 8.25 ± 3.99 days. Emergency tracheostomy was performed in 25% of patients. Mechanical ventilation was required for 50% of our patients. Overall, the mortality rate observed in our study stands at 25%. Conclusion PPD poisoning is associated with a high rate of morbidity and mortality. Therefore, it is imperative for physicians to be mindful of the clinical characteristics and treatment options in order to optimally manage such cases of poisoning. In addition, the use of hair-dyes composed of highly lethal PPD should also be banned.

Telogen Effluvium: A Review of the Literature.

Telogen effluvium is one of the most common causes of alopecia. It is a scalp disorder characterized by excessive shedding of hair. Several factors such as drugs, trauma, and emotional and physiological stress can lead to the development of telogen effluvium. Multiple alterations in the hair cycle have been proposed as the underlying mechanism. Telogen effluvium can present as acute or chronic hair fall with symptoms such as trichodynia. Diagnostic tests that can be used include hair wash test, trichogram, phototrichogram, and scalp biopsy. In the treatment of telogen effluvium, it is essential to identify and remove the causative factors and to use drugs such as corticosteroids, minoxidil, and novel treatments such as CNPDA (caffeine, niacinamide, panthenol, dimethicone, and an acrylate polymer). Herein, we discuss the presentation, diagnostic approaches, and effective treatment options available for telogen effluvium.

Frequency of Human Immunodeficiency Virus in Patients Admitted with Acute Stroke.

Introduction Stroke is a leading cause of chronic disability and death in both developing and developed countries. A significant proportion of stroke patients are human immunodeficiency virus (HIV) positive. About half of the HIV patients experience some sort of neurological deficit in their lifetimes. The exact reason for the occurrence of stroke in HIV infected patients is poorly understood. The purpose of our study is to determine the frequency of HIV among patients admitted with acute stroke. Materials and methods This cross-sectional study is conducted at a major metropolitan hospital in Karachi for six months. A total of 130 patients of stroke between the ages of 30 and 70 years of either gender were included in this study. A complete history was taken and a physical examination was performed. Each patient underwent a battery of tests that included HIV serology, lipid profile, electrocardiography (ECG), chest X-ray (posteroanterior (PA) view), and computed tomography (CT) scan of the brain. Carotid Doppler ultrasonography to assess carotid artery stenosis was also ordered. The means and standard deviations of age and cluster of differentiation 4 (CD4) cell count were calculated. The frequencies and proportions of gender, diabetes mellitus (DM), hypertension (HTN), smoking, obesity, dyslipidemia, carotid artery stenosis, and HIV status were calculated. Stratification was done by applying the chi-square test and assuming p-value ≤0.05 as significant. This helped analyze the association of age, gender, DM, HTN, smoking, obesity, dyslipidemia, and carotid artery stenosis to the frequency of HIV. Results The mean age of the study population was 55.54 ± 11.166 years. There were 39 (30%) patients <50 years of age while 91 (70%) patients were ≥50 years of age. Gender distribution showed that 86 (66.15%) patients were male, and 44 (33.85%) patients were female. Furthermore, 71 (54.62%) patients were hypertensive, 53 (40.77%) were diabetic, 62 (47.69%) were smokers, 49 (37.69%) were obese, 52 (40%) had dyslipidemia, and 77 (59.23%) had carotid artery stenosis. The frequency of HIV was noted at 24 (18.46%). The mean CD4 count was estimated at 241 ± 103.295 cells/mm3. Stratification showed a significant relationship between the frequency of HIV with only gender (p=0.01) and dyslipidemia (p=0.037). Conclusion HIV infection in patients with stroke is not uncommon. Patients who are male, younger in age, have dyslipidemia, belong to a low socioeconomic class, or have a bad sexual history are more likely to have HIV as an underlying cause of stroke. The exact pathogenesis of such a stroke and the role of antiretroviral therapy in the prevention and treatment of this group of stroke are not completely understood and need further analysis.

Presentation and Management of Klippel-Trenaunay Syndrome: A Review of Available Data.

Klippel-Trenaunay Syndrome (KTS) is a rare and sporadic congenital disorder, characterized by the classical triad of port-wine stains, varicosities along with bone and soft tissue hypertrophy. Symptoms of Klippel-Trenaunay Syndrome include pain, swelling, lymphedema, bleeding, superficial thrombophlebitis, and deep vein thrombosis. The etiology remains indistinct and has been attributed to both genetic and environmental factors. In most cases, a thorough history and clinical examination is enough for the diagnosis of Klippel Trenaunay Syndrome. However, when certain complications are present, noninvasive imaging techniques are used for the diagnosis and evaluation of the disease in patients. Due to the diversity of presentation, a multidisciplinary approach is essential for the proper management of such patients. At present, there is no cure for the disease; rather, symptomatic treatment is employed in order to improve the patients' quality of life. In this review, we provide a brief overview of the clinicopathological profile and management of Klippel-Trenaunay Syndrome.