Bhojo Khealani

Predictors of restless legs syndrome in pregnancy: A hospital based cross sectional survey from Pakistan

Restless legs syndrome (RLS) is more common in pregnant women. The objective of our study was to determine frequency of RLS in pregnant women and predictors of RLS in pregnancy in Pakistan. All pregnant women admitted at The Aga Khan University Hospital for delivery from June to July 2005 were enrolled. Eighty-one of 271 (30%) interviewed women fulfilled the diagnostic criteria of RLS. One hundred seventeen (43%) of the subjects dropped their haemoglobin during the pregnancy. No significant difference in haemoglobin drop was noted between the RLS group and healthy group. On multivariate analysis family history of RLS (OR: 8.43, CI: 2.32-30.57, p value<0.001), history of RLS in prior pregnancy (OR: 53.74, CI: 6.72-429.8, p value<0. 001), history of RLS in past even when non-pregnant (OR: 12.91, CI: 3.34-49.87, p value<0.001) and haemoglobin of 11g/dL or less (OR: 2.05, CI: 1.04-4.04, p value 0.036) were found to be independent predictors of RLS during pregnancy. Subgroup analysis revealed that family history of RLS (OR: 3.06, CI: 1.2-7.83, p value 0.019) and anemia (OR: 1.89, CI: 0.96-3.71, p value 0.06) were associated with de novo RLS, and family history of RLS (OR: 12.39, CI: 4.45-35.54, p value<0.001) and multiparity (OR: 6.84, CI: 2.15-21.71, p value 0.001) were predictors of pre-existing RLS.

Neuroimaging of tuberculous myelitis: analysis of ten cases and review of literature

We retrospectively reviewed the clinical and neuroimaging features of 10 patients with tuberculous myelitis. The most common presenting symptoms were fever (70%) and paraplegia (60%). Bladder and bowel symptoms were present in 90% patients. On MRI, the involvement of the cervical/thoracic segment of the spinal cord was most commonly seen (90%). The most consistent finding was hyperintense signals on T2‐weighted MRI. T1‐weighted images showed isointense (n= 5) and hypointense (n= 4) signals in the spinal cord lesions. Post‐contrast enhancement was present in 6 patients, epidural enhancement in 4 patients, and cord swelling in 2 patients.

Autonomic nervous system dysfunction predicts poor prognosis in patients with mild to moderate tetanus

BackgroundAutonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus. The prognostic value of ANS dysfunction is known in severe tetanus but its value is not well established in mild to moderate tetanus.MethodsMedical records of all patients admitted with tetanus at two academic tertiary care centers in Karachi, Pakistan were reviewed. The demographic, clinical and laboratory data was recorded and analyzed. ANS dysfunction was defined as presence of labile or persistent hypertension or hypotension and sinus tachycardia, tachyarrythmia or bradycardia on EKG. Patients were divided into two groups based on presence of ANS dysfunction (ANS group and non ANS group). Tetanus severity was classified on the basis of Ablett criteria.ResultsNinety six (64 males; 32 females) patients were admitted with the diagnosis over a period of 10 years. ANS group had 31 (32%) patients while non ANS group comprised of 65 (68%) patients. Both groups matched for age, gender, symptom severity, use of tetanus immunoglobulin and antibiotics. Twelve patients in ANS group had mild to moderate tetanus (Ablett I and II) and 19 patients had severe/very severe tetanus (Ablett III and IV). Fifteen (50%) patients in ANS group required ventilation as compared to 28 (45%) in non-ANS group (p = 0.09). Fourteen (47%) patients died in ANS group as compared to 10 (15%) in non ANS group (p= 0.002). Out of those 14 patients died in ANS group, six patients had mild to moderate tetanus and eight patients had severe/ very severe tetanus. Major cause of death was cardiac arrhythmias (13/14; 93%) in ANS group and respiratory arrest (7/10; 70%) in non ANS group. Ten (33%) patients had complete recovery in ANS group while in non ANS group 35(48%) patients had complete recovery (p= 0.05).ConclusionsANS dysfunction was present in one third of our tetanus population. 40% patients with ANS dysfunction had only mild to moderate tetanus. ANS dysfunction, irrespective of the need of mechanical ventilation or severity of tetanus, predicted poor outcome.

Knowledge gaps in stroke care: results of a survey of family physicians in Pakistan.

Family physicians play a pivotal role in stroke prevention (primary and secondary) and early management of stroke in developing countries. The objective of this study was to evaluate whether Pakistani family physicians approach to stroke prevention and management was in accordance with established international guidelines. This was a cross-sectional survey of randomly selected family physicians in Pakistan, conducted in 2007. A total of 588 family physicians participated in the study. The data reveal that 88% of the physicians are aware of at least one of the 5 major symptoms of stroke, but only 46% are able to correctly idenitfy all 5 symptoms; 93% of the physicians check blood pressure in their adult patients regularly, and 63% use a cutoff of 140/90 mm Hg to start antihypertensive therapy in routine clinical practice; 90% ask their patients about cigarette smoking or tobacco use, but only 64% regularly advise their patients to quit smoking; 75% do not routinely check cholesterol levels in their patients; 36% treat patients with stroke by themselves, whereas 64% prefer to refer these patients to a specialist or hospital; 57% use intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure >160/100 mm Hg; and 95% use antiplatelet agents for stroke prevention, with 70% using aspirin and 28% using clopidogrel as first-line antiplatelet therapy. These data indicate a substantial gap between international guidelines and Pakistani family physicians management of stroke patients. There is an urgent need for stroke-related continuing medical education to propagate stroke management guidelines.

Risk for sleep apnea syndrome in Pakistan: a cross-sectional survey utilizing the Berlin questionnaire

PurposeThe purpose of this study was to assess the prevalence of individuals at high risk for developing obstructive sleep apnea in the Pakistani population using a validated questionnaire.Materials and methodsThis is a cross-sectional survey using a pre-validated, interviewer-administered questionnaire conducted at the Aga Khan University Hospital. All healthy individuals above 18xa0years of age attending a seminar were included as participants after consent.ResultsThe percentage of people in the high-risk group was calculated to be 12.4% out of a population of 137. Presence of snoring, hypertension, and body mass index >27.5xa0kg/m2 was found to be more prevalent in high-risk individuals.ConclusionsA significant proportion of the population is at high risk for obstructive sleep apnea syndrome.

Ischemic Strokes in Pakistan: Observations from the National Acute Ischemic Stroke Database

BACKGROUNDnThe objective of this study was to establish a multicenter ischemic stroke registry, first of its kind in Pakistan, to provide insight into the epidemiology, subtypes, and risk factors of ischemic strokes in this country.nnnMETHODSnFour academic centers (3 urban and 1 rural) participated in this project. The inclusion criteria for subjects included adults (>14 years) with acute neurologic deficit, consistent with clinical diagnosis of ischemic stroke and supported by neuroimaging.nnnRESULTSnData were available for 874 subjects. Mean age of the subjects was 59.7 years, 60.5% were males, and 18% were young. Large vessel strokes were the most common subtype found in 31.7% subjects, followed by small vessel disease (25.7%) and cardioembolic strokes (10.4%). Almost 32% subjects had ill-defined etiology for their ischemic stroke. Dyslipidemia was a most common risk factor present in 83% patients. Data related to in-hospital complications were available for 808 subjects, of which 233 complications were recorded. Pneumonia was the most common of these seen in 105 (13%) subjects, followed by urinary tract infection (7.2%). Outcome at discharge was recorded for 697 subjects. Ninety-two had died during their hospital stay (13.2%). Only 36% subjects had a favorable outcome at discharge defined as a modified Rankin Scale (mRS) score of 2 or less. A total of 446 of 697 subjects had poor outcome at discharge (defined as an mRS score≥3).nnnCONCLUSIONSnHypertension and dyslipidemia were the most common risk factors and large vessel atherosclerosis was the most common stroke etiology. Elderly patients were significantly more likely to have in-hospital complications, die during their hospital stay, and have a higher mRS score at discharge.

Temporal trends in risk factors and outcome of intracerebral hemorrhage over 18 years at a tertiary care hospital in Karachi, Pakistan.

BACKGROUNDnThe purpose of this study was to analyze the baseline characteristics and outcomes of intracerebral hemorrhage (ICH) patients at our center over the last 18 years.nnnMETHODSnPatients with ICH (first-time) were identified from medical records using International Classification of Diseases, Ninth Revision codes from 1988 to 2005. Patients were divided into 2 groups, with each group spanning 9 years based on the year of admission: the old group (admitted between 1988 and 1996) and the newer group (admitted between 1997 and 2005).nnnRESULTSnOut of 920 patients, the number of admissions with ICH increased from <40 per year (average) during 1988 to 1996 to >60 per year (average) during 1997 to 2005. The findings indicate that the percentage of cases in males decreased from 72% to 55% in the newer group as compared to the older group, while female ICH admissions increased from 28% to 45%. Mean age of ICH onset for both men and women decreased about 5 years, but this difference was not statistically significant. Frequency of diabetes (14% v 30%), dyslipidemia (3% v 18%), and the use of antihypertensive medications (29% v 69%) was higher in newer group, while the frequency of lobar hemorrhage was found to be reduced (40% v 20%) in newer group. Lower mortality (22% in the newer group v 32% in the older group) was noted. A decreased length of hospital stay for the newer group was recorded, but this difference was not found to be statistically significant.nnnCONCLUSIONnThe mean age of ICH onset for both men and women has decreased about 5 years in the newer group. Men and women were equally affected in recent years as compared to male predominance in the older group.

Early Ischemic Stroke Presentation in Pakistan

INTRODUCTIONnThere are no studies from Pakistan that describe stroke presentation rates or factors associated with early or delayed presentation. This is important to know because current clinical protocols limit the use of recombinant tissue plasminogen activator (rtPA), the only available therapy for acute ischemic stroke, to a three-hour window from symptom onset.nnnMETHODSnAll patients aged 14 years or above with acute ischemic stroke of < or = 48 hours duration were prospectively identified from the Aga Khan University Stroke Data Bank over a 22-month period ending May 2001.nnnRESULTSn269 ischemic stroke patients presented within 48 hours of stroke onset. 55 out of 269 (21%) presented within first three hours and 110 out of 269 (41%) within first six hours. Unawareness of treatment options (p < 0.001) and inappropriate diagnosis and field triage (p = 0.005) were associated with delayed presentation. Small vessel occlusion or lacunar stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) ischemic stroke subtype was associated with delayed presentation (p = 0.047) and cardioembolic stroke was associated with earlier presentation (p = 0.048). Stroke severity assessed with the National Institutes of Health Stroke Scale at a cut off score of > or = 15 was not associated with earlier time to presentation at three hours (p = 0.114) but there was some tendency at six hours (p = 0.097).nnnCONCLUSIONSnThe rate of early stroke presentation in a Pakistani tertiary care facility is comparable to certain developed countries. To increase the proportion of patients who can benefit from thrombolytic therapy, programs need to be instituted to increase public awareness of treatment options for stroke and expedited referral by the primary care provider.