Spectrum of Head Trauma at Tertiary Care Military Hospital CMH Quetta, Pakistan

Objective: The objective of this study was to determine the etiological spectrum, injury patterns and outcome of head injured patients at tertiary care military hospital CMH Quetta.Materials and Methods: This descriptive study includes all patients of head trauma coming to trauma centre at CMH Quetta, Pakistan. Patients with associated injuries of other organs were excluded from the study. We noted the detailed clinical history and examination, demographics, mechanism of injury, treatment offered (operative / non operative) and analyzed the details of operative procedure (craniotomy, craniectomy, elevation of compound depressed fracture, scalp suturing), morbidity and outcome (according to Glasgow outcome scale). Data was analyzed using SPSS version 16.Results: There were 1026 patients (856 males and 170 females) eligible to be included in the study. The mean age of the patient was 28.9 ± 19.2 years SD. Majority of the patients belonged to the age group 21 – 40 years. The commonest cause of head injury was Road traffic accident 507 (49.41%), fall 273 (26.6%), gunshot wound 97 (9.45%), bomb blast injury 76 (7.41%), sports related 35 (3.41%), mine blast 25 (2.44%) and splinter injury 13 (1.27%) of patients. CT Brain findings were contusions in 116 (11.3%), isolated fractures in 45 (4.38%), SDH in 44 (4.28%), EDH in 43 (4.19%), DAI (diffuse axonal injury) in 36 (3.51%), compound depressed fractures in 16 (1.55%), frontal sinus fractures in 14 (1.36%), combined EDH / SDH in 6 (0.58%) and normal CT brain findings in 706 (68.81%) patients. 662 (64.52%%) patients were managed conservatively and 364 (35.47%) underwent operative management. Major operations (craniotomy / craniectomy / elevation of compound depressed skull fracture) were performed in 138 (13.45%) and minor operations (suturing of scalp laceration) were performed in 226 (22.03%). Good recovery was seen in 894 (87.13%), moderate disability in 26 (2.53%) and severe disability in 12 (1.16%) whereas 16 (1.56 %) patients remained vegetative. The mortality was 78 (7.6%).Conclusion: In Pakistan, head injury contributes significantly to mortality and morbidity. Road traffic accident, history of fall and gunshot are the commonest causes of head injury. Appropriate medical care facilities needs to be established at district and tehsil level to provide prompt and adequate care to head injured patients

Role of Ventriculoperitoneal Shunt for Haemorrhagic or Ischemic Strokes Causing Hydrocephalus

Posterior fossa hemorrhagic involve or infract associated hydrocephalus are serious neurosurgical emergencies which requires immediate and prompt action.Purpose: To highlight the role of VP shunt in the management plan of Hydrocephalus caused by spontaneous hemorrhagic or ischemic infarcts.Material and Methods: This is retrospective study of 16 cases over a period of 4 years from March 2007 to March 2011 conducted simultaneously at Neurosurgical departments of CMH Lahore, CMH Multan and Farooq Hospital Lahore.Results: A total of 16 cases were included in this study and all those patients underwent some sort of CSF diversion procedure for obstructive hydrocephalus. Ten Patients (62.5%) were male and six (37.5%) patients were female. The age ranged from 32 – 70 years with mean age of 53.4 years. Clinically all patients presented with headache, vomiting and neck pain followed by loss of consciousness. Glasgow coma scale ranged from 5/15 to 12/15. The radiological findings were those of hemorrhagic or ischemic infarcts causing obstructive hydro-cephalus. Patients were broadly divided into two main groups with eight patients in each group. Group A inclu-ded 6 males and 2 females, all these patients were managed conservatively for the hemorrhagic or ischemic strokes while they underwent VP Shunt for the obstructive hydrocephalus. Two of these patients (a male and a female) had thalamic bleed (hemorrhagic stroke) with third ventricular blockade. These two patients were also managed by VP Shunt only. Outcome of patients in group A was excellent in 7 patients whereas one patients developed complications with prolonged hospital stay but ultimately recovered and discharged. Group B inclu-ded 8 patients (4 male and 4 female) who underwent hematoma evacuation of cerebellar bleed along with place-ment of external ventricular drain (EVD). EVD was converted to VP Shunt in six patients when they deteriorated after blocking EVD on 5th post operative day. 2 patients out of these eight did not deteriorate on EVD blockade and VP Shunt was not passed in these patients and they had excellent recovery. One patient died in group B. One patient required redo surgery due to Shunt Blockade and had poor recovery whereas two more patients had poor recovery due to other reasons including poor neurological status pre operatively. Two patients had fairly good recovery after converting EVD into VP Shunt.Conclusion: Obstructive hydrocephalus caused by hemorrhagic stroke or infarcts is a relatively rare entity requiring some sort of CSF diversion. Patients who are having smaller hematomas with hydrocephalus and GCS more than 8/15 can be managed with VP Shunt alone

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

Cigarette Smoking Habits among University Students: Prevalence and Associated Factors

Smoking is the main cause of morbidity and mortality in the world and is estimated to kill 5 million people each year worldwide. If current patterns of tobacco consumption continue, smoking will kill more than 8 million people each year globally by the year 2030, with 80% of these deaths in the developing countries. This study aimed to determine the prevalence and associated factors of cigarette smoking among male university students in Muzaffarabad, Pakistan. A descriptive cross-sectional study was conducted among 542 male students at University of Azad Jammu & Kashmir in Muzaffarabad from July to December 2015. The socio-demographic characteristics and cigarette smoking behavior of the students were measured by using a standardized pre-tested self-administrated validated questionnaire in English. The overall prevalence of cigarette smoking among students was found to be 49.4%. The mean age of starting cigarette smoking was 19.2 2.73 years. Age, marital status and education were found significantly associted with cigarette smoking behavior (p-value<0.05). The most common reason for cigarette smoking was stress alleviation (35.0%) followed by peer pressure (24.5%). As cigarette smoking is considerably higher among students. There is a need to develop effective tobacco control measures among university students in Muzaffarabad

Clinical parameters and treatment outcome in patients of acromegaly: A retrospective analysis of 51 patients

The aim of the study was to analyze the pattern of clinical presentation and management outcome in patients of acromegaly. It is a cross-sectional study based on the clinical records of 51 patients of Acromegaly. All the recorded clinical data was analyzed to see the pattern of clinical presentation and management outcome. IBM SPSS statistics version 22 was used for statistical analysis. The median age was 32 years. Twenty seven patients underwent surgery and 6 (22.2%) achieved remission. With pharmacological management, 35.8% patients achieved control of the disease with Octreotide LAR and 7.1% with cabergoline. Eighteen patients were treated with External Beam Radiation (EBR) and Stereotactic Radiosurgery (SRS). Remission rate has been 88.9% with SRS and 33.3% with EBR. The study shows higher prevalence of Growth Hormone (GH) secreting tumour in younger people and men. Remission rate was highest in patients treated with radiotherapy after partial response to TSS. Keywords: Acromegaly, trans-sphenoidal surgery, radiotherapy, Octreotide. Continuous..

Multi-Objective Task-Aware Offloading and Scheduling Framework for Internet of Things Logistics

IoT-based smart transportation monitors vehicles, cargo, and driver statuses for safe movement. Due to the limited computational capabilities of the sensors, the IoT devices require powerful remote servers to execute their tasks, and this phenomenon is called task offloading. Researchers have developed efficient task offloading and scheduling mechanisms for IoT devices to reduce energy consumption and response time. However, most research has not considered fault-tolerance-based job allocation for IoT logistics trucks, task and data-aware scheduling, priority-based task offloading, or multiple-parameter-based fog node selection. To overcome the limitations, we proposed a Multi-Objective Task-Aware Offloading and Scheduling Framework for IoT Logistics (MT-OSF). The proposed model prioritizes the tasks into delay-sensitive and computation-intensive tasks using a priority-based offloader and forwards the two lists to the Task-Aware Scheduler (TAS) for further processing on fog and cloud nodes. The Task-Aware Scheduler (TAS) uses a multi-criterion decision-making process, i.e., the analytical hierarchy process (AHP), to calculate the fog nodes’ priority for task allocation and scheduling. The AHP decides the fog nodes’ priority based on node energy, bandwidth, RAM, and MIPS power. Similarly, the TAS also calculates the shortest distance between the IoT-enabled vehicle and the fog node to which the IoT tasks are assigned for execution. A task-aware scheduler schedules delay-sensitive tasks on nearby fog nodes while allocating computation-intensive tasks to cloud data centers using the FCFS algorithm. Fault-tolerant manager is used to check task failure; if any task fails, the proposed system re-executes the tasks, and if any fog node fails, the proposed system allocates the tasks to another fog node to reduce the task failure ratio. The proposed model is simulated in iFogSim2 and demonstrates a 7% reduction in response time, 16% reduction in energy consumption, and 22% reduction in task failure ratio in comparison to Ant Colony Optimization and Round Robin

Multi-Objective Task-Aware Offloading and Scheduling Framework for Internet of Things Logistics

IoT-based smart transportation monitors vehicles, cargo, and driver statuses for safe movement. Due to the limited computational capabilities of the sensors, the IoT devices require powerful remote servers to execute their tasks, and this phenomenon is called task offloading. Researchers have developed efficient task offloading and scheduling mechanisms for IoT devices to reduce energy consumption and response time. However, most research has not considered fault-tolerance-based job allocation for IoT logistics trucks, task and data-aware scheduling, priority-based task offloading, or multiple-parameter-based fog node selection. To overcome the limitations, we proposed a Multi-Objective Task-Aware Offloading and Scheduling Framework for IoT Logistics (MT-OSF). The proposed model prioritizes the tasks into delay-sensitive and computation-intensive tasks using a priority-based offloader and forwards the two lists to the Task-Aware Scheduler (TAS) for further processing on fog and cloud nodes. The Task-Aware Scheduler (TAS) uses a multi-criterion decision-making process, i.e., the analytical hierarchy process (AHP), to calculate the fog nodes’ priority for task allocation and scheduling. The AHP decides the fog nodes’ priority based on node energy, bandwidth, RAM, and MIPS power. Similarly, the TAS also calculates the shortest distance between the IoT-enabled vehicle and the fog node to which the IoT tasks are assigned for execution. A task-aware scheduler schedules delay-sensitive tasks on nearby fog nodes while allocating computation-intensive tasks to cloud data centers using the FCFS algorithm. Fault-tolerant manager is used to check task failure; if any task fails, the proposed system re-executes the tasks, and if any fog node fails, the proposed system allocates the tasks to another fog node to reduce the task failure ratio. The proposed model is simulated in iFogSim2 and demonstrates a 7% reduction in response time, 16% reduction in energy consumption, and 22% reduction in task failure ratio in comparison to Ant Colony Optimization and Round Robin

Special considerations for the treatment of multiple myeloma according to advanced age, comorbidities, frailty and organ dysfunction.

Multiple Myeloma (MM) is primarily a disease of old age with a median age of sixty-nine years at diagnosis. The development of novel therapies for induction and use of autologous stem cell transplantation has resulted in improved clinical outcomes and better quality of life for MM patients. Elderly patients, comprising the majority of MM population, have a higher incidence of age-related comorbidities, frailty and organ dysfunction which complicates the coordination of treatment and limits the selection of therapies. Even in the era of multiple chemotherapeutic options, the clinical heterogeneity of the myeloma patients\u27 demands personalized treatments which often require dose-adjustments or dose delays. The use of reduced-dose regimens and various comorbidity indices has improved clinical outcome and regimen tolerability in MM patients with renal, neurological and bone abnormalities. We focus on advancements in the treatment of multiple myeloma with the goal to guide clinicians towards patient-specific management