White coat hypertension is not a benign entity: a cross-sectional study at a tertiary care hospital in Pakistan

OBJECTIVES: To determine the frequency of White Coat Hypertension in patients undergoing ambulatory blood pressure monitoring at a tertiary care center and to compare ambulatory blood pressure profiles of normotensives, white coat hypertensives and hypertensives.METHODS: A descriptive cross-sectional study was conducted which included all adult patients undergoing ambulatory blood pressure monitoring over a 3-year period. Those patients with incomplete data, less than 85% successful BP readings and inadequate number of daytime and nighttime readings were excluded from the study. The data on ambulatory blood pressure monitoring comprised of demographics, blood pressure, pulse pressure and mean arterial pressure readings at every 30 minutes interval and also a graphical representation of patients\u27 24-hour blood pressure recording. SPSS was used for data analysis. Chi-square test and analysis of variance (ANOVA) was used for qualitative and quantitative variables respectively.RESULTS: A total of 277 patients with a mean age of 48.98 +/- 17.52 years were included. There were 189 (58%) males included in the study. Out of the total, 46 (16.6%) patients had White Coat Hypertension, 59 (21.3%) were Normotensive and 172 (62.1%) had Hypertension. The mean age of Normotensives was 40.80 +/- 14.11 years, White Coat Hypertensives was 37.72 +/- 14.58 years and Hypertensives was 54.80 +/- 16.76 years (

Fuzzy logic: A “simple” solution for complexities in neurosciences?

Background: Fuzzy logic is a multi-valued logic which is similar to human thinking and interpretation. It has the potential of combining human heuristics into computer-assisted decision making, which is applicable to individual patients as it takes into account all the factors and complexities of individuals. Fuzzy logic has been applied in all disciplines of medicine in some form and recently its applicability in neurosciences has also gained momentum.Methods: This review focuses on the use of this concept in various branches of neurosciences including basic neuroscience, neurology, neurosurgery, psychiatry and psychology.Results: The applicability of fuzzy logic is not limited to research related to neuroanatomy, imaging nerve fibers and understanding neurophysiology, but it is also a sensitive and specific tool for interpretation of EEGs, EMGs and MRIs and an effective controller device in intensive care units. It has been used for risk stratification of stroke, diagnosis of different psychiatric illnesses and even planning neurosurgical procedures.Conclusions: In the future, fuzzy logic has the potential of becoming the basis of all clinical decision making and our understanding of neurosciences

Good knowledge about hypertension is linked to better control of hypertension; A multicentre cross sectional study in Karachi, Pakistan

Back Ground: According to the National Health survey only 3% of the population has controlled hypertension. This study was designed to elucidate the knowledge about hypertension in hypertensive patients at three tertiary care centers in Karachi. Secondly we sought to compare the knowledge of those with uncontrolled hypertension and controlled hypertension. Methods: It was a cross-sectional study conducted at The Aga Khan University hospital (AKUH), Ziauddin Hospital (ZH) and Civil hospital, Karachi (CHK. All diagnosed Hypertensive patients (both inpatients and outpatients) coming to a tertiary care hospital in Pakistan aged \u3e 18 years were included. Patients were categorized into 2 groups: controlled and uncontrolled hypertension based on their initial BP readings on presentation Uncontrolled Hypertension was defined as average BP ≥ 140/90 mm Hg in patients on treatment. Controlled Hypertension(HTN) was defined as average BP \u3c140/90 mm Hg in patients on treatment. Standardized methods were used to record BP in the sitting position. Knowledge was recorded as a15 item question. Primary outcome was knowledge about hypertension. Results: A total of 650 participants were approached and consented 447 were found eligible. 284(63.5%) were from Aga Khan University, 101(22.6) from Dow University of health sciences and 62(13.9) were from Ziauddin University. Mean (SD) age of participants was 57.7(12) years, 50.1(224) were men. Controlled hypertension was present in 323(72.3) and uncontrolled hypertension was present in 124(27.4). The total mean (SD) Knowledge score was 20.97(4.93) out of a maximum score of 38. On comparison of questions related to knowledge between uncontrolled and controlled hypertension, there was statistically significant different in; meaning of hypertension (p \u3c0.001), target SBP(p0.001), target DBP(p 0.001), importance of SBP versus DBP, improvement of health with lowering of blood pressure (p 0.002), high blood pressure being asymptomatic (p \u3c0.001), changing lifestyle improves blood pressure(p 0.003),hypertension being a lifelong disease (\u3c0.001), lifelong treatment with antihypertensives(\u3c0.001) and high blood pressure being part of aging(\u3c0.001). On comparison of knowledge as a composite score between uncontrolled and controlled hypertensive; Mean (SD) score was 21.85(4.74) v18.67 (4.70) (p value: \u3c 0.001). On multivariate analysis; gender β (95% CI) 1.67(0.75, 2.59) p \u3c0.001, uncontrolled blood pressure; -2.70(-3.76,-1.67) p \u3c0.001, Sindhi ethnicity; -1.79(-3.25,-3.27) p 0.01 and pukhtoon ethnicity; -2.72(-4.13,-1.32) p \u3c0.001 were significantly associated with knowledge score. Conclusion: Knowledge about hypertension in hypertensive patients is not adequate and is alarmingly poor in patients with uncontrolled hypertension. More emphasis needs to be made on target blood pressure and need for taking antihypertensives for life to patients by physicians

Clinical review of pediatric pilocytic astrocytomas treated at a tertiary care hospital in Pakistan

Abstract Background: Pilocytic Astrocytoma (PA) is a common type of brain tumor in the pediatric population. They have a fairly good prognosis. This study describes PAs in detail, with a focus on the demographic factors, presenting features, management and prognosis, and aims, to identify the negative outcome predictors in our population, which can affect the course of the disease. This article will add to the understanding of PAs from a third world perspective. Methods: The Aga Khan University medical records (1995 – 2007) were reviewed, to study the clinical features, management, and outcome of patients (0 – 15 years) with Pilocytic Astrocytomas (PAs) in our population. After a thorough review of the medical records, all the PAs diagnosed on the basis of histopathology at our Pathology Laboratory, during this period, were included in the study. Results: Twenty-two patients were included with a mean age of 9.25 years. Male-to-female ratio was 1 : 1. The most common presenting feature was a sign of increased intracranial pressure. The most common location was the cerebellum followed by the cerebrum. Fifteen patients underwent maximum surgical resection. Three had recurrence, despite no residual tumor. There were 10 Intensive Care Unit (ICU) admissions and one inpatient mortality. Fifteen patients followed up in the clinic: Eight had recurrence and four underwent repeat surgery (three showed clinical improvement). Hydrocephalus was a predictor of ICU admission. Solid consistency was found to be a marker of recurrence. Conclusion: Pilocytic Astrocytomas are the most common pediatric brain tumors in our population, commonly located in the cerebellum. Complete resection is the best treatment option, but some tumors are aggressive and recurrence is not uncommon. The possible negative outcome predictors are age, source of admission, extent of resection, hydrocephalus, and solid consistency

Research-retreat-recovery: A potential model for organization and completion of research projects. Experience from a neurosurgery department in a developing country

Background: In the current era of biomedical research, it is imperative that every research study at an institution is properly organized, and frequently audited to streamline efforts and maintain standards. Recently, a research retreat was organized by the Section of Neurosurgery at Aga Khan University Hospital, Karachi, Pakistan, and following that a recovery team was made with the aim of recovering lost in translation research projects. In the realm of our experience, the current model is being proposed as a means for organization of departmental research.Methods: The research component of the model comprised compilation of an abstract book of all research work done within the section during the last five years. The retreat component of the model was intended with objectives of analysis of past research and generation of fresh ideas. The recovery component of the model was accomplished by formation of a research recovery team with the aim of recovering unfinished, and/or unpublished research projects.Results: The abstract book comprised 103 abstracts: 52.4% original research studies, 12.6% review articles, and 34.9% case report/series. Only 8.7% abstracts were of basic science research whereas the remaining 91.3% were clinical research papers. Only 34% had been published in an article form in a biomedical research journal (51.4% in international journals and 48.6% in national journals); remaining papers were either in submission/preparation process or had been abandoned. As part of research recovery, 29.4% projects were recovered within 12 weeks of the retreat component.Conclusion: We conclude that the model of research-retreat-recovery is highly successful in the context of neurosurgery departments in developing countries without a proper research unit, and can result in better organization of departmental research, recovery of unfinished projects, and initiation of new research studies

A critical analysis of the current state of neurosurgery training in Pakistan

Objective: To observe interdepartmental variation in the availability of resources and academic activities within the various neurosurgery programs of Pakistan.Methods: This was a proforma-based survey of neurosurgery trainees and young neurosurgeons of Pakistan, looking at the academic infrastructure and output of their programs. The proforma was filled by 36 respondents from 11 neurosurgery centers of the country. All these centers were accredited for neurosurgery training in Pakistan.Results: Out of the 36 respondents, 30 were completing a Fellowship training (FCPS) and six were enrolled for a Master in Surgery (MS) program. About 80% of the participants used the Youman\u27s Textbook of Neurosurgery as a reference book. Only 40% of the candidates had access to more than one indexed neurosurgery journal. Structured academic sessions (e.g., journal clubs and neuropathology meetings) were lacking in a majority of the training institutes, 95% of the trainees had no microsurgical laboratory experience, and modern neurosurgical tools (frameless neuronavigation system, neuroendoscopy) were in use at a few centers only.Conclusion: Neurosurgery training in Pakistan is not uniform and wide variations exist between the programs at the centers evaluated. We recommend exchange programs between centers at national and international levels, to allow trainees to gain first-hand exposure to training components not available in their own center

Cranial reconstruction after decompressive craniectomy: Prediction of complications using fuzzy logic

Introduction: Cranial reconstruction after decompressive craniectomy (DC) has been shown to be associated with a relatively high complication rate (16.4%-34%) compared with standard neurosurgical procedures (2%-5%). Most studies that have previously attempted to formulate a multivariate model for identifying factors predictive of postoperative complications of cranioplasty either were unsuccessful or yielded conflicting results. Therefore, fuzzy logic-based fuzzy inference system (FIS), which has proven to be a useful tool for risk prediction in medical and surgical conditions, was used in this study to identify predictors of complications of cranioplasty. Methods: A retrospective chart review of all the patients who underwent DC followed by elective cranioplasty at Aga Khan University Hospital, during a 10-year period (2000-2010), was carried out to collect data on 24 carefully selected preoperative variables or inputs. The proposed FIS had 24 inputs, 3 outputs, and a set of 7 fuzzy-based rules. All inputs were assigned degrees of membership, and complications were further divided into "severe," "minor," and "least" output classes with each of them representing 2 membership functions: "less" and "more." For each set of inputs, a specific portion of the hypersurface was masked out. The centroid of this subsurface represented the defuzzified output corresponding to 1 percentage value for each output. The maximum of these outputs for each of the 3 output classes was selected to be the final output class. Each output class was compared to the actual outcome of patients, and positive predictive value, negative predictive value, sensitivity, and specificity of FIS for predicting complications were calculated. Results: A total of 89 patients (mean [SD] age, 33.1 [15.0] y; male-to-female ratio, 3:1) were included in the study. The common postoperative complications included seizures (14.6%), cerebrospinal fluid leak (4.5%), neurologic deficits (3.4%), hydrocephalus (3.4%), superficial wound infection (3.4%), and osteomyelitis (2.2%). The FIS correctly identified all 7 patients who developed severe complications after cranioplasty (true positives) and all 82 patients who did not develop severe complications (true negatives). Thus, the FIS has a sensitivity and specificity of 100% in predicting severe complications. Conclusions: Our study shows that the procedure of cranioplasty is associated with a high complication rate and that FIS has a 100% sensitivity and specificity in predicting severe complications after cranioplasty. It will prove to be an invaluable tool for clinicians once the results are validated by a similar prospective study with a larger sample size.Scopu

Lack of improvement after audit assessing the management of voiding dysfunction in patients with spinal cord injury: Necessity for institutional guidelines

Introduction: Standard management guidelines for voiding dysfunction in Patients with spinal cord injury (SCI) do not exist and these Patients are managed on the basis of institutional protocols or individual judgment of managing physicians. Objectives: To notice general trends and improvements over a five-year period, in the institutional practices related to management of voiding dysfunction in SCI Patients. Methodology: A retrospective cross-sectional study was conducted by Neurosurgery and Urology services together. A nine years (June 1995-June 2004) internal clinical audit of urological management of SCI Patients was compared with a similar audit conducted five years later (January 2008-June 2010). Comparisons were made using chi-square test. A p-value of Results: A total of 146 Patients were compared (89-pre-audit, 57-post-audit). The quality of documentation of examination findings worsened over the two study periods (p = 0.002). Although determination of baseline serum creatinine improved to statistically significant levels (p = 0.019), no imaging for the kidneys was performed as baseline in the post-audit period (p = 0.000). Similarly the number of urodynamic studies performed decreased from 11% to 1.75% (p = 0.045). The number of urological consultations, however, increased from 26% to 31.58% (p = 0.452). During follow-up, only 17 (19.1%) Patients in the pre-audit study period and 6 (10.5%) in the post-audit study period were voiding spontaneously. Conclusion: Our study of two eras clearly demonstrated a worsening trend in quality of Patient management, which can be corrected by agreeing upon and implementing standard guidelines for management of SCI Patients

Time trends and age-related etiologies of pediatric hydrocephalus: results of a groupwise analysis in a clinical cohort

Objective: The current study aimed at evaluating experience with pediatric hydrocephalus and reviewing time trends and age-related differences in etiology, management, and outcomes of pediatric hydrocephalus at a tertiary care center in a south Asian country. Methods: We conducted a retrospective cohort study based on case note review of pediatric Patients (age, 1 month to 15 years) with hydrocephalus managed at Aga Khan University Hospital Karachi, over an 18-year period (1988-2005). For analysis, the study period was divided into two epochs (period A, 1988-1996, period B, 1997-2005) and study population was divided into two age groups (0-12 months and 1-15 years). Results: A total of 338 cases of pediatric hydrocephalus were identified. Most common etiology of pediatric hydrocephalus was meningitis (38.1%), followed by congenital hydrocephalus (20.4%) and brain tumors (8.3%). Shunt infection and blockage were seen in 38 (11.2%) and 54 (16.0%) children, respectively, 67 (19.8%) required shunt revision. Highest rates of shunt failure were seen in bacterial meningitis (35.3%) and aqueductal stenosis (29.2%). Neurological and/or cognitive deficits were observed more frequently in children under 1 year of age (P=0.029). Duration of hospital stay in period A was significantly higher than in period B (PConclusion: Despite recent advancements, hydrocephalus is still associated with high rate of shunt failure and mortality. Factors associated with poor outcome include younger age group and etiology of hydrocephalus

Time trends and age-related etiologies of pediatric hydrocephalus: results of a groupwise analysis in a clinical cohort

Objective: The current study aimed at evaluating experience with pediatric hydrocephalus and reviewing time trends and age-related differences in etiology, management, and outcomes of pediatric hydrocephalus at a tertiary care center in a south Asian country. Methods: We conducted a retrospective cohort study based on case note review of pediatric Patients (age, 1 month to 15 years) with hydrocephalus managed at Aga Khan University Hospital Karachi, over an 18-year period (1988-2005). For analysis, the study period was divided into two epochs (period A, 1988-1996, period B, 1997-2005) and study population was divided into two age groups (0-12 months and 1-15 years). Results: A total of 338 cases of pediatric hydrocephalus were identified. Most common etiology of pediatric hydrocephalus was meningitis (38.1%), followed by congenital hydrocephalus (20.4%) and brain tumors (8.3%). Shunt infection and blockage were seen in 38 (11.2%) and 54 (16.0%) children, respectively, 67 (19.8%) required shunt revision. Highest rates of shunt failure were seen in bacterial meningitis (35.3%) and aqueductal stenosis (29.2%). Neurological and/or cognitive deficits were observed more frequently in children under 1 year of age (P=0.029). Duration of hospital stay in period A was significantly higher than in period B (PConclusion: Despite recent advancements, hydrocephalus is still associated with high rate of shunt failure and mortality. Factors associated with poor outcome include younger age group and etiology of hydrocephalus