Comparison Of Potential Plasma Biomarkers In Alzheimer's Disease And Neurodegenerative Dementias In Pakistani Population.

This study aimed to compare the mean plasma levels of Amyloid ß42, Phosphorylated Tau and Neurofilament Light chain in patients diagnosed with Alzheimer's Clinical Syndrome (ACS), and other neurodegenerative dementias to find affordable and less-invasive means of diagnosing Alzheimer's disease (AD) early in its course. Blood samples of 36 subjects presenting with cognitive decline to the neurology OPDs of Dow and Civil hospitals, Karachi, were centrifuged, and plasma was stored at -80℃. Before analysis, it was thawed at 4℃ and protein levels were measured through ELISA. Two-thirds of the patients were females but age distribution across both the groups was not significantly different (p=0.21). No difference was observed in the mean plasma concentrations of Aß42, P-Tau, and NFL between the two groups (p-values 0.78 and 0.27 and 0.09 respectively). Our study suggests that despite being promising in CSF, Aß42, P-Tau, and NFL cannot differentiate between different neurodegenerative dementias when measured in plasma.

Neurological disorders and disability in Pakistan: A cross-sectional multicenter study.

BACKGROUND/OBJECTIVE: The aim of this study is to identify frequencies of various neurological disorders (NDs) and associated disability in patients attending neurologic clinics in rural and urban centers in Pakistan. METHODS: This is an observational study conducted in 39 neurological centers in both rural and urban areas, public and private health sectors all over Pakistan. This study was conducted between august 2017 to December 2019. RESULTS: A total of 28,845 adults were enrolled. Mean age of the study participants was 46.2 ± 17.2 years, 15,252 (52.9%) were men and 13,593 (47.1%) were women. Most common comorbid medical condition was hypertension 7622(26.4%) followed by Diabetes 3409(11.8%). Among neurological diagnoses, vascular diseases (20%) were the most common followed by Headache disorders (18.6%), Epilepsy (12.5%), nerve and root diseases (12.4%), Psychiatric diseases (10%), Dementias (8%) and movement disorders (7.9%). Half of the patients 15,503(53.7%) had no neurological disability, while minor disability was present in 10,442(36.2%) of cases. Moderate to severe disability was present in 2876(10%) cases. Headache disorders, psychiatric diseases, muscle pain/muscle related disorders and demyelinating diseases were more common in women. Vascular diseases, movement disorders and Dementias were more common in 46 years and above age group whereas headache disorders, Epilepsy and Psychiatric disorders were more prevalent in <46 years age groups. CONCLUSION: Vascular diseases are the most common presentation of patients in neurology clinics followed by headache disorders and epilepsies. Minor disability was present in 36% while moderate to severe disability was present in 10% cases.

Targeting Anti-Inflammatory Pathways to Treat Diabetes-Induced Neuropathy by 6-Hydroxyflavanone.

It is evident that inflammation and metabolic syndrome instigated by diabetes mellitus can precipitate diabetes-induced neuropathy (DIN) and pain. In order to find an effective therapeutic method for diabetes-related problems, a multi-target-directed ligand model was used. 6-Hydroxyflavanone (6-HF) carrying anti-inflammatory and anti-neuropathic pain potential due to its quadruplicate mechanisms, targeting cyclooxygenase-2 (COX-2), 5-lipoxygenase (5-LOX), and opioid and GABA-A receptors was investigated. The anti-inflammatory potential of the test drug was confirmed utilizing in silico, in vitro, and in vivo tests. A molecular simulation approach was utilized to observe the interaction of 6-HF with the inflammatory enzyme COX-2 as well as opioid and GABA-A receptors. The same was confirmed via in vitro COX-2 and 5-LOX inhibitory assays. In vivo tests were performed to analyze the thermal anti-nociception in the hot-plate analgesiometer and anti-inflammatory action in the carrageenan-induced paw edema model in rodents. The potential anti-nociceptive effect of 6-HF was evaluated in the DIN model in rats. The Naloxone and Pentylenetetrazole (PTZ) antagonists were used to confirm the underlying mechanism of 6-HF. The molecular modeling studies revealed a favorable interaction of 6-HF with the identified protein molecules. In vitro inhibitory studies revealed that 6-HF inhibited the COX-2 and 5-LOX enzymes significantly. The 6-HF at dosages of 15, 30, and 60 mg/kg substantially reduced heat nociception in a hot plate analgesiometer as well as carrageenan-induced paw edema in rodent models. The authors discovered that 6-HF had anti-nociception properties in a streptozotocin-induced diabetic neuropathy model. According to the findings of this study, 6-HF was demonstrated to diminish inflammation caused by diabetes as well as its anti-nociception effect in DIN.

Plasma levels of phosphorylated tau and neurofilament light chain as potential biomarkers for Alzheimer's disease: A biochemical analysis in Pakistani population.

The National Institute on Aging-Alzheimer's Association's research framework in 2018 proposed a molecular construct for the diagnosis of Alzheimer's disease (AD). Nonetheless, the clinical exclusionary strategy is still the mainstay of AD diagnosis in Pakistan. We looked at the plasma levels of amyloid beta-42 (Aß-42), phosphorylated tau (P-tau), and neurofilament light (NFL) in patients with Alzheimer's clinical syndrome (ACS) and healthy controls (HC) from the Pakistani population to keep pace with the global efforts towards establishing accessible and affordable biochemical diagnostic markers for AD in Pakistan. Consultant neurologists screened patients who presented with cognitive impairment to three large tertiary care hospitals in Karachi, and after receiving informed consent, recruited participants with ACS and HC from the same facilities. We collected 5cc of blood in EDTA tubes along with demographic and lifestyle information of the subjects. Plasma aliquots were stored at -80°C after centrifugation. For analysis it was thawed at 4℃ and levels of the three proteins were measured through ELISA. Data from 28 ACS patients and 28 age matched healthy controls were evaluated. Among demographic factors, education and depression were related with health status (p = 0.03 and 0.003, respectively). NFL and P-tau mean values demonstrated a significant difference between the ACS and control groups (p = 0.003 and 0.006), however Aß42 did not (p = 0.114). ROC analysis showed that plasma P-tau and NFL, with AUCs of 0.717 and 0.735, respectively, could substantially distinguish ACS from the HC group (p = 0.007 and 0.003, respectively). Both plasma P-tau (r = -0.389; p = 0.004) and NFL (r = -0.424; p = 0.001) levels were significantly and negatively correlated with individuals' MMSE scores. NFL and plasma P-tau show promise in differentiating AD patients from healthy individuals. However, similar larger studies are needed to validate our findings.

Prevalence of the Usage of Smokeless Tobacco in Patients Presenting With Stroke in a Tertiary Care Hospital.

Background Stroke is one of the leading causes of disability, long-term morbidity, and mortality. The key modifiable risk factors for stroke are largely driven by demographic changes and various social adaptations. Smokeless tobacco consumption is high in developing countries with less awareness of its potential health risks. Aim This study was designed to determine the prevalence of usage of smokeless tobacco in patients presenting with stroke in a tertiary care hospital in Karachi. Methods This is a cross-sectional study conducted at the Department of Neurology of Dr. Ruth K. M. Pfau Civil Hospital in Karachi. A total of 192 patients were enrolled during the study period of six months, from September 2018 to March 2019. All consenting patients were recruited who presented with stroke and fulfilled the inclusion criteria. All patients were assessed by a trained neurologist. Results A total of 192 patients with stroke were included. There were 146 (76%) males and 46 (24%) females with a mean age of 53 ± 6.1 years. The highest percentage (39%) of cases was illiterate. A majority (64%) of patients presented belonged to a lower socioeconomic background. Out of 192 stroke patients, 131 (68.2%) consumed smokeless tobacco.  Conclusion The frequency of smokeless tobacco consumption was found to be high in stroke patients who require the attention of the physician on modifiable risk factors.

Factors affecting prognosis of status epilepticus among patients presenting to a tertiary care hospital.

OBJECTIVES: This study aimed to evaluate the etiology, outcomes and prognostic factors associated with status epilepticus (SE) admissions in Neurology Department of a tertiary care hospital. METHODS: A retrospective review was performed on all SE admissions at Dr. Ruth K.M. Pfau Civil Hospital Karachi over a five-year period from July 2015 to June 2020. Demographic, clinical, and etiological factors were investigated for prognostic value. Statistical tests were applied to determine significant prognostic factors. A five percent significance level was used. RESULTS: A total of 176 patients were included in the study. Mortality was reported in 22 cases (12.5%) and morbidity at six months was observed in 44 cases (25.0%). Male gender, previous history of SE, prolonged seizure duration, and late presentation to hospital were significantly associated with mortality (p<0.05). De novo cases of SE tended to be older (p=0.048) and were associated with morbidity at follow-up (p=0.000). The most common causes of epilepsy in our patients with SE were CNS infections (n=54) and Idiopathic epilepsy (n=34). Non-compliance to medicines/under-dosing was the most common provocative factor (n=68). Acute symptomatic causes of SE were more likely to be associated with greater morbidity (p=0.000). Refractory and super-refractory SE were strongly associated with higher mortality (p=0.000). A longer duration of hospital stay was associated with higher morbidity (p=0.000). CONCLUSION: Male gender, poor control of seizures, CNS infections, prolonged seizures, delayed hospital arrival and refractory/super-refractory status epilepticus were key determinants of mortality in our setting. Previous history of status epilepticus, and acute and symptomatic etiologies were associated with higher morbidity.

Relationship between cerebrospinal fluid protein level and electrophysiologic abnormalities in the acute inflammatory demyelinating polyradiculoneuropathy variant of Guillain-Barré syndrome.

Objective: Guillain-Barré syndrome (GBS) is an autoimmune disease characterized by weakness in limbs or cranial nerve innervated muscles. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common variant. Electrophysiologic abnormalities and elevated cerebrospinal fluid (CSF) protein are frequently present in AIDP, but the relationship between these two parameters is not well known. We aimed to fill this gap by studying this relationship. Methods: This was a prospective cross-sectional study conducted for two years in the Department of Neurology, Dr. Ruth K. M. Pfau Civil Hospital, Karachi, Pakistan. All 90 adult patients with the AIDP variant of GBS were selected. Nerve conduction studies were performed to determine the degree of demyelination through the four electrophysiologic demyelination criteria. The CSF sample was sent to lab immediately after lumbar puncture. SPSS version 20.0 was used. The CSF protein level was measured with mean ±SD. Demyelination criteria were measured in frequency and percentages. Chi-square test was applied to a number of demyelination criteria and T-test/ANOVA was applied on mean CSF protein level. Results: We found a mean CSF protein of 37.41 mg/dl (±3.69) with one demyelination criterion, 81.87 mg/dl (±17.39) with two demyelination criteria, 119.75 mg/dl (±31.42) with three demyelination criteria, and 134.00 mg/dl (±42.87) with four demyelination criteria (P-value <0.001). Conclusion: This study demonstrates a significant relationship between CSF protein levels and degree of demyelination in the AIDP variant of GBS. This is an under-researched area in GBS and this study adds favorably to limited data in this regard.

Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (CO-VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. METHODS: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. RESULTS: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0-1 at discharge. CONCLUSION: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Preparedness and impact of COVID 19 infection at tertiary care neurology centers in Pakistan.

OBJECTIVE: We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training. METHODS: A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals. RESULTS: Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers. CONCLUSIONS: Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Association Between Hyperuricemia and Acute Ischemic Stroke in Patients at a Tertiary Care Hospital.

Introduction Stroke is the most debilitating of neurologic diseases. The rationale of the current study was to determine the association between hyperuricemia and ischemic stroke to establish a local perspective. Methods A total of 148 patients at a tertiary care hospital in Pakistan who fulfilled the inclusion criteria were enrolled in the study and then equally distributed into two study groups consisting of cases and controls (n = 74 in each group). In this study, there were 36 (48.6%) participants in the case group with hyperuricemia and ischemic stroke and 18 (24.3%) participants in the control group with hyperuricemia. The mean and standard deviations were computed for quantitative variables such as age, body mass index (BMI), and duration of stroke. Frequencies and percentages for the qualitative variables such as gender, hypertension, type 2 diabetes (T2D), dyslipidemia, smoking status, socioeconomic status, educational level, and hyperuricemia were calculated. The chi-square test was applied to compare both groups, with p ≤ 0.05 indicating significance. The odds ratio was also calculated to determine the association between case and control. Effect modifiers were controlled through stratification of age, gender, BMI, duration of stroke, hypertension, T2D, dyslipidemia, socioeconomic status, educational level, and smoking status to determine the effect of these on outcome variables. A post-stratification chi-square test was applied, with p ≤ 0.05 indicating statistical significance. Results In our study, stratification of hyperuricemia into cases and controls was performed for age, gender, T2D, hypertension, dyslipidemia, smoking status, socioeconomic status, and educational status. The maximum results were significant, with high strength of association between both groups. In the case group, the frequency of elevated uric acid was significantly higher than that of the control group. A comparison of hyperuricemia indicated p = 0.002, with an odds ratio of 2.95, which showed that elevated uric acid could be taken as a predictor of ischemic stroke. The uric acid level was significantly higher in men than in women. Additionally, hyperuricemia was associated with dyslipidemia. In patients with ischemic stroke, there was a significant association between serum uric acid level and T2D, hypertension, and smoking. Conclusions This study showed that the prevalence of hyperuricemia in patients with ischemic stroke was significantly higher as compared to the healthy population. Hyperuricemia can be considered as a risk factor for ischemic stroke because of its high prevalence in ischemic stroke patients. Our study explored the relationship between stroke and hyperuricemia and enabled increased understanding for caregivers so that effective management plans can be formulated for patients with ischemic stroke to prevent adverse outcomes.

Etiology and Types of Seizures in Patients Presenting to a Tertiary Care Hospital in Karachi: A Cross-Sectional Study.

Introduction Epilepsy is a burdensome disorder for affected individuals and community. There is limited data available on the epidemiological aspects of seizures in Pakistan and further research is necessary. We aimed to fill this gap by studying this information in epilepsy patients presenting to our neurology department. The purpose of this study is to evaluate the causes and types of seizures among the target population. Method This is a cross-sectional study conducted at the Department of Neurology, Dr. Ruth K.M. Pfau Civil Hospital Karachi. In this study we evaluated the causes and types of seizures among patients presenting to our department during the two-year study duration (January 2018-December 2019). Informed consent was taken. Detailed history was taken including features of seizure episodes, age at first seizure, family history and comorbid conditions. Relevant investigations were carried out. The data was compiled to deduce the relevant information using SPSS v20.0. T-test and Chi-square were used for analyzing the data. Results A total of 996 patients presented during the study duration. Primary seizures were found in 58% cases while secondary seizures were found in 42% cases. This distribution was more equal in children with 49.6% primary seizures and 50.4% secondary seizures; the gap widened in adults with 64.3% primary seizures and 35.7% secondary seizures. The most common cause of secondary seizures was neonatal encephalopathy which was present in 18.7% patients, followed by traumatic head injury in 18.2% patients. Central nervous system (CNS) infection was the cause in 17.9% patients, cerebral tumors in 14.1% patients, stroke in 11.5%, metabolic encephalopathy in 7.4%, febrile seizures in 6.5% and CNS malformations in 5.7% patients. The top three causes in children were neonatal encephalopathy (28.3%), CNS infections (19.3%) and febrile seizures (12.7%). Adults with secondary seizures were diagnosed most often with head trauma (25.2%), cerebral tumors (19.9%) and stroke (18.4%) as causative factors. The most common type of seizures was generalized onset tonic-clonic seizures which was found in 73.0% patients followed by focal to bilateral tonic-clonic seizures in 8.9% patients. Other types of seizures included focal aware seizures in 5.0%, mixed seizure types in 4.2%, focal impaired awareness seizures in 3.1%, absence seizures in 2.7%, myoclonic seizures in 2.0% and atonic seizures in 1.0% patients. Seizures in children were mostly generalized onset tonic-clonic seizures (75.4%), mixed seizure types (5.7%) and focal to bilateral tonic-clonic seizures (5.2%). In adults the three most common types corresponded to the overall result: generalized onset tonic-clonic seizures (71.2%), focal to bilateral tonic-clonic seizures (11.6%) and focal aware seizures (6.6%). Conclusion We found that the most common cause of seizures overall in our study population was primary seizures, though primary and secondary seizures were more evenly present in children. Among secondary causes neonatal encephalopathy stood out as the most common cause in children; head trauma was the predominant cause in adults. Most common type of seizures overall and in adults was generalized onset tonic-clonic seizures, followed by focal to bilateral tonic-clonic and focal aware seizure types. Pediatric patients presented most often with generalized onset tonic-clonic seizures, followed by mixed seizure types and focal to bilateral tonic-clonic seizures.

Cost of Investigating Neurological Disease: Experience of a Tertiary Care Center in Karachi, Pakistan.

INTRODUCTION:  Neurological disorders, structural or functional, are prevalent all over the world and are accompanied by physical and social morbidity. In this study, we aimed to calculate the cost of investigating neurological disorders and compare the costs incurred in a government hospital with that in a private hospital. MATERIALS AND METHODS:  This study was conducted at the Dr. Ruth KM Pfau Civil Hospital, Karachi, Pakistan. One hundred patients were enrolled in the study; 10 each investigated for epilepsy, cerebrovascular accidents (CVAs), headache, neuropathy, myopathy, cranial nerve palsies, movement disorders, demyelinating diseases, central nervous system (CNS) infections, and dementia. Receipts and records in the patients' medical history were used for the calculation of the cost of procedures, which was then compared with the costs of these investigations in a private hospital. A bottom-up costing approach was taken with individual costs being estimated and then being grouped to calculate the overall economic burden of the disorders. Data were analyzed using IBM SPSS version 23.0. One-way analysis of variance (ANOVA) was done to compare the mean cost (taken by the patient, covered by the government, total cost in the government hospital, and total cost in the private hospital) across diseases in government and private hospitals separately. Pearson correlation and scatter plot were also done to study the cost in private and public hospitals. p-values less than 0.05 were considered statistically significant. The margin of error in the study was 5%. RESULTS:  The mean age was 38.2 ± 20.5 years. Some 51% data were received from female samples. The mean income of samples was 13863.6 ± 9715.9 Pakistani Rupees (PKR) or 78.38 ± 58.29 United States Dollars (USD). The mean cost covered by government hospitals was 8866.0 ± 5071.0 PKR (53.19 ± 30.42 USD) per patient, whereas in government hospitals patients were charged on average 2662.9 ± 3774.7 PKR (16 ± 22.65 USD), while in private hospitals patients paid on average 29041.3 ± 12992.6 PKR (174.21 ± 78 USD). CONCLUSION:  The costs of investigations in private hospitals were approximately three times the costs in government hospitals. The maximum cost was generated by patients being investigated for demyelinating disorders. Investigations conducted in government-run hospitals are more cost effective and these institutions should receive increased funding to cater to the maximum number of patients.

6-Methoxyflavanone abates cisplatin-induced neuropathic pain apropos anti-inflammatory mechanisms: A behavioral and molecular simulation study.

Cisplatin is used as a first line therapy in treating cancers. However, its use is often accompanied with the development of peripheral neuropathy. 6-Methoxyflavanone (6-MeOF) is a positive allosteric modulator at GABAA receptors and is known for attenuating diabetes-induced neuropathic pain. Neuropathy was induced in male Sprague-Dawley rats (150-250 g), via intraperitoneal injection of cisplatin (3 mg/kg) once a week for four consecutive weeks. 6-MeOF (25, 50 and 75 mg/kg, i.p) and gabapentin (75 mg/kg, i.p) were administered 30 min before each cisplatin injection. Static and dynamic allodynia were assessed using von Frey filaments and cotton buds. The anti-inflammatory activity was analyzed with plethysmometer. Body weights were also measured each week. The binding affinity of 6-MeOF with chloride channel, Cyclooxygenase-1 (COX-1) and Cyclooxygenase-2 (COX-2) was studied using docking approach. The in vitro COX-1 and COX-2 inhibitory effect of 6-MeOF was conducted with COX colorimetric assay. Administration of cisplatin for four consecutive weeks induced static (decreased paw withdrawal threshold; PWT) and dynamic allodynia (decreased paw withdrawal latency; PWL). Co-administration of 6-MeOF for four weeks significantly attenuated the cisplatin-induced expression of nocifensive behaviors observed as significant increase in PWT and PWL. Moreover, it also prevented the body weight loss induced by cisplatin administration. In silico studies depicted a good interaction of 6-MeOF with chloride ion channels and COX-1 and COX-2 enzymes. The in vitro study confirmed the inhibitory activity of 6-MeOF for COX-1 and COX-2. 6-MeOF may be effective in attenuating cisplatin-induced allodynia, probably through interaction with GABAergic receptors and reducing inflammation.

Frequency of Autonomic Dysfunction in Patients of Guillain Barre Syndrome in a Tertiary Care Hospital.

Introduction Guillain-Barré syndrome (GBS) is defined as a syndrome manifesting as an acute inflammatory demyelinating polyradiculoneuropathy (AIDP) with coexistent weakness and absent or diminished reflexes clinically.Autonomic dysfunction (AD) or dysautonomia is a common finding in GBS. Autonomic dysfunction usually occurs in the acute phase of the illness but can also be seen in the recovery phase. The rationale of our study is to determine the frequency of autonomic dysfunction in patients of GBS admitted to the Neurology department of Civil Hospital, Karachi. Methods A total of 118 admitted patients at a tertiary care hospital in Pakistan who fulfilled the inclusion criteria were enrolled in the study after informed consent. The study was conducted for six months at the department of neurology, Civil Hospital, Karachi. Patients were assessed for autonomic dysfunction by recording blood pressures and pulse rate hourly (both lying and standing positions) by resident doctors. Urinary retention, diarrhea, and constipation were also recorded in a separate chart. All values entered in the pre-approved performa by researchers. The data was collected and analyzed on Statistical Package for Social Sciences (SPSS) version 18.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics included mean, standard deviation (SD) of continuous data, like age, duration of illness, motor weakness assessment by Medical Research Council (MRC) Scale, protein content in cerebrospinal fluid (CSF), pulse, and blood pressure at the time of presentation. Frequencies and percentages were calculated from the categorical data, like gender and patients with autonomic dysfunction (outcome variable). Effect modifiers were controlled by stratification of age, gender, duration of illness. Post-stratification chi-square test was applied with a p-value of ≤ 0.05 taken as significant. Results In our study, the average age of the patients was 39.90±9.91 years. Frequency of autonomic dysfunction among patients with GBS was 41.53% (49/118). The most frequent autonomic manifestations were constipation and diarrhea; 22% and 21.2% respectively. Additional manifestations included urinary retention (15.3%) and fluctuation of blood pressure and heart rate at 13.6% each.  Conclusion This study showed that the frequency of autonomic dysfunction among patients of Guillain Barre Syndrome was significant, consistent with previous studies. Our study explored the adverse outcomes of autonomic dysfunction in patients with GBS. This will help physicians increase their understanding of dysautonomia so that effective management plans can be formulated for patients with GBS to prevent adverse outcomes and hence provide better patient care.

Clinical Features Indicating the Need for Mechanical Ventilation in Patients with Guillain Barre Syndrome.

Background Guillain Barre Syndrome (GBS) is an immune-mediated inflammatory polyradiculoneuropathy. Respiratory failure is one of its recognized and most dreaded complications, requiring ventilatory assistance. Early recognition of distinct clinical predictors of mechanical ventilation may help in the better management of GBS patients in our setup. Objective To determine the clinical predictors indicating the need for mechanical ventilation in patients with Guillain Barre Syndrome and to compare the presenting features in patients who require mechanical ventilation and who do not. Method It was a prospective observational study. A total of 100 consecutive patients, over the period of one year, were included in this study. All patients were clinically examined for limb weakness, neck weakness, bulbar and facial nerve involvement, and followed up till seven days of hospitalization for whether the patient required mechanical ventilation or not. Results were recorded on a specifically designed proforma. Data were entered and analyzed using SPSS version 20.0 (IBM Corp., Armonk, NY, US). Results Out of 100 patients, 13% required mechanical ventilation. When clinical presentations were compared in patients who required mechanical ventilation and those who did not, a shorter interval between the onset of symptoms and the attainment of maximal disability, facial weakness, bulbar dysfunction, and neck weakness turned out to be significant factors (p-value<0.000). Conclusion According to these significant outcomes of our study, the course of patients with GBS leading to mechanical ventilation can be predicted on the basis of clinical presentations. So we can recommend that shorter time duration between symptom onset and peak disability, along with the presence of facial, bulbar, and neck weakness, should be taken as an indication of impending respiratory failure.

Levetiracetam Induced Increase in Creatine Phosphokinase Levels.

Levetiracetam is an antiepileptic drug used for the treatment of generalised or partial seizures, either alone or in a combination therapy. Adverse effects have been reported with its clinical use, including headache, dizziness, liver failure etc. A rare but an important adverse effect is an increase in creatine phosphokinase (CPK) levels with its use. Herein, we present a case of 43-year male, known intravenous (IV) drug abuser with a history of decompressive craniotomy. Patient presented with severe behavioural disorder for which risperidone was given. Five days later, he started having high grade fever, hyperventilation and uncontrolled generalised tonic-clonic seizures (GTCS). After initial management of seizures, levetiracetam was started in combination with topiramate for seizure control. Seizures remained subsided but CPK levels, which were normal at the start of therapy, began to rise and reached tremendous levels of 29,000 mg/dl within a span of a week. Levetiracetam, suspected as a cause of this increase CPK levels, was stopped immediately and the levels returned to baseline within one week. This report provided us with an important step in the management of seizures with levetiracetam.

Simultaneous determination of moxifloxacin and ofloxacin in physiological fluids using high performance liquid chromatography with ultraviolet detection.

A novel, sensitive and validated RP-HPLC-UV method was developed for simultaneous determination of moxifloxacin and ofloxacin using timolol maleate as internal standard in physiological fluids. Different experimental parameters were optimized and validated according to international guidelines. Complete separation of the analytes was achieved with Kromasil 100-5C18 analytical column (250mm×4.6mm×5µm), methanol and 0.05% trifloroacetic acid (TFA) (38:62v/v) were used as mobile phase, pumped at flow rate of 1.1ml/min in isocratic phase, column oven temperature maintained at 45°C and detection wavelength of 290nm. Protein precipitation method was applied to extract the drugs from human plasma and bovine aqueous humor samples using methanol as precipitating solvent. This method is linear in concentration range of 0.018-100µg/ml for moxifloxacin and 0.014-20µg/ml for ofloxacin. The recoveries of the method were 97.52 and 97.39% in human plasma for MX and OFN respectively, while in aqueous humor 94.48% for MX. The LOD values in plasma were found to be 10.0 and 8.00ng/ml for MX and OFN respectively, while their respective LOQ values were 18.0 and 14ng/ml. In aqueous humor the LOD and LOQ for MX were 16.0 and 24ng/ml respectively. In future, this method will be used to study the pharmacokinetic profile of moxifloxacin and ofloxacin in biological fluids and pharmaceutical products.

Validation Study of the Mini-Mental State Examination in Urdu Language for Pakistani Population.

UNLABELLED: Validation study of the Mini-Mental State Examination in Urdu language for Pakistani population. OBJECTIVE: This study was conducted primarily to validate and determine the optimal cutoff score in the diagnosis of dementia among Pakistani's and study the effects of gender and education on the MMSE performance in our population. METHODS: Four hundred participants took part in the study. Patient with dementia recruited from five major hospitals from Pakistan. The MMSE was translated into Urdu. RESULTS: There were 61 men and 39 women in dementia group and 225 men and 75 women in the control group. The mean score of Urdu MMSE were lower in patients with dementia 18.5 ± 5.6 (range 0-30) as compared to the controls 26.8 ± 2.6 (range 7-30). This difference between groups was statistically significant (p<0.001). Educational based MMSE score below 15 yielded perfect sensitivity and specificity for the diagnosis of dementia. CONCLUSIONS: These finding confirm the influence of level of education on MMSE score and education stratified cutoff scores should be used while screening for cognitive impairment in this population.

Development and evaluation of pluronic- and methylcellulose-based thermoreversible drug delivery system for insulin.

The objective of the current work was to develop and evaluate thermoreversible subcutaneous drug delivery system for Insulin. Thermoreversible in-situ gel system was developed and evaluated both in-vitro and in-vivo comprising of pluronic F-127 alone or in combination with methylcellulose in different ratios. The drug release kinetics and mechanism was predicted by applying various mathematical models to the in-vitro dissolution data. Rabbits were used as animal model following subcutaneous injection to predict various pharmacokinetic parameters by applying Pk-Summit® software. The in-vitro and in-vivo data revealed that the formulation IPM 15/3 consisting of the pluronic F-127 (15% w/v) and methylcellulose (3% w/v) was the most robust and capable formulation for extending the drug release and maintaining basal plasma insulin level between 10 and 40 µU/ml for 240 h (10 d).

Method development and validation for simultaneous determination of lumefantrine and its major metabolite, desbutyl lumefantrine in human plasma using RP-HPLC/UV detection.

A simple, specific, precise and rapid RP-HPLC-UV method was developed for simultaneous determination of lumefantrine and its metabolite desbutyl lumefantrine in human plasma. Experimental parameters were optimized and the method was validated according to standard guidelines. The method showed adequate separation for lumefantrine and desbutyl lumefantrine and best resolution was achieved with Supelco Discovery HS C18 RP (150mm×4.6mm, 5µm) column using acetonitrile and 0.05% trifluroacetic acid (70:30, v/v) as a mobile phase pumped at a flow rate of 1.0ml/min and wavelength of 335nm. The method was linear over the concentration range of 10-12,000ng/ml. The lower limit of detection (LLOD) and lower limit of quantification (LLOQ) for lumefantrine were 10.0 and 18.0ng/ml, while for desbutyl lumefantrine were 7.5 and 15.0ng/ml, respectively. The proposed method was efficiently applied for determination of lumefantrine and desbutyl lumefantrine concentrations in plasma samples for pharmacokinetic studies.