Clinical Pattern and Post-Operative Complications of Post Tuberculous Meningitis Hydrocephalus in Patients Underwent Ventriculoperitoneal Shunt

Objective: To determine the clinical presentation of post tuberculous meningitis hydrocephalus and post-operative complications in patients underwent placement of a ventriculoperitoneal shunt.Study Design: This Quasi-experimental study was conducted at Department of Neurosurgery of Dow University of Health Sciences/ Civil Hospital, Karachi. Study duration was six months from October 2013 to March 2014.Methodology: Total 40 patients were studied who were diagnosed as cases of tuberculous meningitis and hydrocephalus on the basis of history, clinical examination, CSF findings, CT and MRI. Each patient underwent placement of a ventriculoperitoneal shunt. All the data regarding clinical presentation and postoperative complications was recorded in the proformaRESULTS: Total 40 patients having tuberculous meningitis hydrocephalus were selected; their mean age was 16.4+07.8 years. Male were found in the majority 62.50%, as compared to female 37.50%. According to the clinical presentation, most patients 70.0% were presented with a headache and 62.50% with fever, followed by nausea and vomiting was in 37.5% patients, Neck rigidity was in 27.50% cases, extra neural tuberculosis in 25.0% patients, papilledema in 22.50% cases, limb weakness in 10.0% patients, while fits were found only in 5.0% of the patients. Past history of tuberculosis was in 7.50% patients. According to postoperative complications infection was found in 10.0% of the cases, peritoneal pseudo-cyst without infection was in 7.5% cases, while 10.0% patients died. No significant difference was found in the postoperative complications according to gender p-value 0.94.Conclusion: It is concluded that a headache, fever and nausea/vomiting were the commonest clinical features and the Ventriculoperitoneal shunt is relatively simple and suitable for the patients of all age groups with hydrocephalus, its complications are relatively easy to manage

Pancreatic Involvement in Hermansky–Pudlak Syndrome- A Case Report

Hermansky-Pudlak Syndrome (HPS) is a rare autosomal recessive disorder that presents with oculocutaneous albinism, bleeding disorders, and immunodeficiency. Granulomatous colitis and pulmonary fibrosis are two major complications of this syndrome. On rare instances, HPS can involve the heart and lungs. This report discusses a 32-year-old man who presented with oculocutaneous albinism and immunodeficiency along with renal, pulmonary, and pancreatic complications. Pancreatic atrophy is a unique finding in our patient, which has not been reported in the literature. The purpose of our case report is to bring into light unusual complications of HPS so that timely action could be taken to avoid the progression of complications.&nbsp

SERUM VITAMIN-D ANALYSIS: A CROSS SECTIONAL SURVEY AT LUMHS

Vitamin D is very important in children for teeth and bones development, its deficiency results in rickets while in adults it may present as osteomalacia, osteoporosis and arthritis causing joint pain. Supplementations (Oral or injectable) are required if serum levels fall below normal (30-50 ng/ml). Observational study conducted at LUMHS Jamshoro from November 2016 to November 2017. We evaluated 800 patients following selection through Probability sampling under inclusion and exclusion criteria analyzing the obtained data on SPSS version 22 using Student’s t-test. There were 429(53.63%) male and 313(46.37%) females Vitamin –D. Mean of the serum vitamin –D levels was15.61+9.64 ng/ml in men while it was 17.02+12.57ng/ml in women. 69.5% of the study population was found deficiency <20ng/ml while 15.5% were having insufficient levels<30ng/ml and only 15% showed normal levels 30-50ng/ml. There was a significant difference between the two genders with p value 0.082 Conclusion: Vitamin –D was found deficient in the study subjects with non-significant gender difference statistically. Key words: Vitamin-D, Osteoporosis, Arthritis, Ricket

Overview on virosomes as a novel carrier for drug delivery

As from the last eras number of the revolution in the drug delivery technologies have been seen to attain the targeted drug delivery or site specific action of the drug. The prospects of the drug delivery by using biomimetic nanoparticles such as virosomes is an motivating research &amp; development field as showing targeted action by fusion with the targeted action by fusion through target cell. It can be engaged as vehicle &amp; vaccines furthermore victory of virosomal drug delivery depends on the method used to make the encapsulated bioactive materials, characterization &amp; formulation of finished products. They are reconstituted viral envelopes that can be conveyance of different macromolecules as these are biocompatible, biodegradable, nonautoimmunogenic. Virosomes denotes such a unique system for presentation of antigen to immune system. Peptides, nucliecacid &amp; medications such as antitoxins, anticancer agents &amp;steroids can be encapsulated. This review focus on various aspects of Virosomes, such as Structure of Virosomes Component, Advantages, disadvantages, Method of preparation, Characterization, recent Patents and applications of Virosomes etc. Key words: Neurodegenerative, Nonimmunogenic, Endolysosomal, Cryoprotectants, Applications

SPONTANEOUS BACTERIAL PERITONITIS: A COMMON AND LETHAL COMPLICATION OF CHRONIC LIVER DISEASE

Objective: To determine the frequency and pattern of spontaneous bacterial peritonitis in patients with chronic liver disease. Patients and Methods: Total fifty patients of age ≥12 years and either gender had liver cirrhosis (known / diagnosed cases) with ascites were included in this six months cross sectional study. The ascitic fluid analysis was done by taking 10 ml of ascitic fluid in a 10 CC sterilize syringe and ascitic fluid neutrophil count greater than 250 cells/µL was considered to be the case of SBP. The frequency and percentages was calculated for categorical variables whereas the numerical statistics were used to compute mean ±SD in SPSS 16. Results: During six months study period total fifty patients with chronic liver disease were evaluate for spontaneous bacterial peritonitis. The mean ± for age (years) & duration of chronic liver disease (years) for whole population was 45.62±5.98 & 7.93 ±2.41 respectively. The SBP observed in 37 (74%) while the common pathogen detected were E. Coli 10 (27%), S. aureus (18.9%) and Klebsiella 6 (16.2%) whereas regarding outcome 26 (70.2%) patients were recovered, recurrence observed in 5 (13.5%) and mortality in 6 (16.2%) respectively. Conclusion: SBP is a common and recurrent complication of cirrhosis and the ascitic fluid examination including culture and sensitivity is more sensitive and best tool as far as diagnose and management is concerned Keywords: Spontaneous bacterial peritonitis, Chronic liver disease, Hepatitis B and Hepatitis C

A Practitioner’s Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel

Aim To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner’s toolkit for insulin motivation in the management of diabetes mellitus (DM). Background Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization. Review Results After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy. Conclusions In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016. METHODS: We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15-60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone. FINDINGS: Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5-24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates-a measure of relative inequality-increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7-87·2), and for men in Singapore, at 81·3 years (78·8-83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, an