Pattern and Practice of Paediatric Neurosurgical Procedures- An analysis of one year initial experience at resource challenged setup of Children Hospital, Faisalabad.

patients presenting to Children Hospital, Faisalabad. Materials and Methods:  Retrospective case series of 778 consecutive cases admitted in Pediatric Neurosurgery Department, Children Hospital, Faisalabad over one year (October 2019- September 2020). Patients of age less than 15 years, any gender, admitted in Pediatric Neurosurgery ward for management were included and studied for their demographic data hospital stay, a procedure done and outcome. Results:  A total of 778 patients who required some neurosurgical intervention were admitted, 725 underwent various types of procedures and the remaining were treated conservatively. 320 (44.14%) were male and405 (55.86%) were female. The age range was 20 days to 13 years. The most common diagnosis was hydrocephalous, and then was Meningomyelocele (MMC). The first three common procedures performed included monitoring of Cerebrospinal fluid (CSF) in 36% of cases, Placement of shunt (21%), and placement of external ventricular drain (EVD) in 13% of cases of cerebrospinal fluid (CNS) infections in patients of hydrocephalous. Conclusion:  Pattern of presentation of pediatric neurosurgical cases take in almost all types of diseases like neural tube defects, hydrocephalous, cranial trauma, tumors, cysts, and infections but surgical procedures in routine practice in Faisalabad district cover mainly hydrocephalous and its complications. Endoscopic or advanced procedures are not commonly practiced due to multiple factors but existing constraints do not prevent the best management of pediatric neurosurgery patients

COVID-19 Pandemic: Influences on the Practice of Neurosurgeons all over Pakistan

Objective:  The aim of this survey was to observe the impacts of COVID-19 pandemic on neurosurgery practices during this pandemic, assess various types of adaptations taken by them, protective measures during patient examination and effects on their health, family and socioeconomic life. Material & Methods:  A Questionnaire comprising 32 questions was circulated among practicing Neurosurgeons of Pakistan by social media, e-mails for 8 weeks (January-February 2021) and their responses were analyzed. Results:  108 participants were involved from all over Pakistan. 32% respondents stated reduction in clinical practice to a level of less than 25%. While, 10% reported complete closure of outpatient services during pandemic. There were varied responses on the use of protective measures and most used N95 mask only (31%). Pandemic also affected the research work, finances and leisure time activities. Conclusion:  Our study showed that neurosurgical practice was influenced by COVID-19 pandemic in many aspects in Pakistan. Proper method of protective measures and COVID testing of patients were lacking among them. Neurosurgeons should follow standard guidelines according to institutional directives in local neurosurgical practices so as to avoid being influenced by such crisis.

Serum calcium and magnesium abnormalities in patients with status epilepticus: a single centre tertiary care experience

Electrolyte imbalances frequently cause seizures, and these seizures may be the sole presenting symptom. Seizures are especially common in patients with sodium disorders, hypocalcemia, and hypomagnesemia. Successful management of patient seizures begins with the establishment of an accurate diagnosis of the underlying electrolyte disturbance, because rapid identification and correction of the disturbance is necessary to control seizures and prevent permanent brain damage. Objectives: To delineate the percentage of people with status epilepticus having calcium and magnesium deficiencies at admission. Methods: The study was carried out from April 2013 to October 2013 at Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan. Seventy patients diagnosed with status epilepticus were enrolled in the study and frequencies of serum calcium & magnesium abnormalities were measured and compared. Results: Calcium level was low in 29 (41.4%) patients. Magnesium level was low only in 7 (10%) patients. Both calcium & magnesium levels were low in 7 (10%) patients. Among the known epileptics, 16 (76.1%) were on regular antiepileptic treatment. Among those on antiepileptic drugs, 8 (50%) had low calcium levels while 6 (37.5%) had low magnesium levels. Conclusion: Serum calcium level was lower in nearly half while magnesium in nearly 2/5th of the previously diagnosed epileptics who presented in status. Among those on antiepileptic drugs, 50% had low calcium levels while 37.5% had low magnesium levels. It is suggested that all epileptic patients, especially those on long term AEDs, should at least be worked up once in detail for electrolyte abnormalities as timely identification and correction can help reduce the morbidity and mortality associated with future status epilepticus

Albuminocytological dissociation in different electrophysiological gbs variants

The objective of our study was to determine the distribution of different electrophysiological variants of GBS and its relationship with albuminocytological dissociation (ACD). The rationale of the study was to determine whether presence or absence of albuminocytological dissociation has any association with NCS findings and whether can be relied upon as an indirect predictor of axonal variant which warrants poor patient out comes versus demyelinating. Materials and Methods: A consecutive series of 76 patients who presented at PIMS over a 12 month period with GBS were included. Nerve Conduction studies (NCS) and Electromyographic (EMG) findings with CSF characterization for albuminocytological dissociation were recorded. P value \u3c 0.05 was taken significant. Results: NCS revealed AIDP as the most common variant (44; 57.8%) followed by AMAN (19; 25%) and AMSAN (7; 9.2%).For 5(6.5%) patients with normal NCS, EMG revealed early neuropathic changes in 4 (80% of normal NCS; 5.2% of total) (suggesting axonal degeneration). Total axonal degenerative type accounted for (AMAN + AMSAN + axonal neuropathy on EMG=30) 39.4% while demyelinating (AIDP + prolonged/absent F-wave=45) 59.2%. ACD was found in 60 (78.9%) patients.There was no signification association between ACD and NCS variants (p\u3e0.05). Conclusion: AIDP is the most prevalent (58%) GBS variant in our population, at least in the vicinity of Islamabad. There is high prevalence of axonal variants (≈40% of total) as compared to Western countries. There is no correlation between ACD and NCS variants. ACD cannot be used as an independent predictor of NCS variant. Presence or absence of ACD has no definite predilection for axonal variant which itself warrants poor patient outcomes versus demyelinating type

Brain Abscesses in Children: A Study of Microbiological Spectrum and Outcome of 80 Cases

Objective:  Brain abscess is a focus of pus in the brain due to infection somewhere else in the body. It is common in males than females and the average age in children ranges from 4 to 7 years. It develops by skull trauma or contiguous or hematogenous spread of infection. The study aimed to identify the pattern of microbiological involvement in the etiology of pediatric brain abscesses and the outcome so as to enable us to ensure definitive treatment with the appropriate and specific antimicrobial regimen. Materials and Methods:  A prospective study was conducted in 80 pediatric patients of brain abscess admitted to the Pediatric Neurosurgery Department, Children Hospital, Lahore, Pakistan. Results:  The median age was 5.2 years with a predominance of males (60%). The most common presentation was fever (72.5%) and then fits (35%). Congenital heart disease was the commonest factor in 32% of cases. Streptococcus was a commonly isolated pathogen in 17% cases out of 70% of culture positive cases. Recovery was seen in 70% of cases and the mortality was 7.5%. Conclusion:  Congenital heart disease is the most common causative factor in pediatric brain abscesses and most of the abscesses were found culture negative. There is a pressing need to carry out multicenter studies over a large sample size over extended study duration in developing countries to help establish guidelines in treating pediatric brain abscesses

Etiology of stroke in young pakistani adults; results of a single center study

The aim of this study was to determine the demographic profile and incidence of young stroke at a tertiary care setup in Islamabad, Pakistan. Materials and Methods: This single centre, cross sectional study was conducted by recruiting 119 patients of either gender, ≥ 12and ≤ 45 years of age with stroke and receiving care at Pakistan Institute of Medical Sciences, Islamabad. Results: Total number of young strokes was 119 out of a total of 322 strokes i-e-, 36.9 %; 1/3rd strokes were in ≤ 45 years of age. Ischemic arterial strokes were 47% (56 out of 119) while venous ischemic strokes were 11.7 % (14 out of 119) and almost all in females (13 out of 14; 92.8 %).Infective causes of central nervous system were identified in24.3 % (29 out of 119). 49 patients (41.1 %) had hemorrhagic strokes. Major individual risk factors for stroke included hypertension identified in 35 (29.4 %)followed by diabetes mellitus in 8 (6.7 %) patients. Amongst infectious causes, CNS tuberculosis was the major infection associated with young stroke i-e-, 89.6 % (26 out of 29). Conclusion: Nearly 1/3rd of strokes in our population are in young.While risk factors in general for stroke stand true for young stroke as well namely hypertension and diabetes, CNS infections are a major cause of young stroke in Pakistan; particularly CNS TB. While majority of strokes in elderly are ischemic, strokes in young comparatively are almost equally divided between ischemia and hemorrhage i-e-, 1.4:1. 1/5th of these ischemic strokes are due to cerebral venous thrombosis. National level guidelines should therefore adopt different strategies for primary and secondary prevention, laboratory work up and imaging, and treatment of stroke in young

Under recognized entity: chronic inflammatory demyelinating polyneuropathy with lupus

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired, autoimmune peripheral neuropathy. It has an insidious disease progression resulting in a debilitating illness. It is a well known neurological disorder. The causative factors are elucidating and it is generally considered idiopathic. However, its’ associations with various systemic disorders is well established albeit under recognized, especially with lupus as evident by few of the case reports/ series published in the recent past. The aim of this report is to highlight this neglected but important aspect of clinical neurology in common practice

Poly[[di-μ-aqua-(μ-4-formyl-2-meth­oxy­phenol­ato)disodium] 4-formyl-2-meth­oxy­phenolate]

In the title coordination polymer, {[Na2(C8H7O3)(H2O)4](C8H7O3)}n, all the non-H atoms except the water O atoms lie on a crystallographic mirror plane. One sodium cation is bonded to four water O atoms and one vanillinate O atom in a distorted square-based pyramidal arrangement; the other Na+ ion is six-coordinated by four water O atoms and two vanillinate O atoms in an irregular geometry. One of the vanillinate anions is directly bonded to two sodium ions, whilst the other only inter­acts with the polymeric network by way of hydrogen bonds. In the crystal, a two-dimensional polymeric array is formed; this is reinforced by O—H⋯O hydrogen bonds, which generate R 2 1(6) and R 2 2(20) loops

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

An unusual case of bloody tears

Conjunctival bleeding although occurs in many pathological conditions enlisting diseases like purulent conjunctivitis, infection with epstian bar virus, and accidental damage to conjunctiva. We report here a rare case of bloody tears which was accompanied with severe headache in a12-years school-going girl