Saad Shafqat

Holter monitoring in the diagnosis of stroke mechanism

Abstract

Drug compliance after stroke and myocardial infarction: A comparative study

BACKGROUND Stroke and myocardial infarction (MI) are both life-threatening diseases of vascular origin with a tendency to recur. In both conditions, risk of recurrence is reduced through similar drug regimens. AIM To determine if compliance with prescribed medication after stroke or MI was similar in the two populations. SETTING AND DESIGN Retrospective data collection and cross-sectional telephonic survey of patients discharged from a single academic medical center. MATERIALS AND METHODS Adult patients consecutively discharged over a two-year period with a diagnosis of first-ever stroke (ischemic or hemorrhagic) or first-ever MI (ST-elevation) were identified through ICD-9 codes. Clinical details were abstracted from hospital records. Medication compliance was assessed through a structured telephone interview. STATISTICAL ANALYSIS Bivariate analysis using Chi-square and Fisher exact tests, to determine the prevalence of noncompliance in stroke versus MI patients and differences in baseline characteristics and multivariate analysis with logistic regression to determine independent predictors of noncompliance. RESULTS Follow-up data was collected for 298 stroke and 275 MI patients. Compliance was lower in stroke patients (68% stroke patients compliant with at least half their discharge prescriptions versus 90% MI patients; P < 0.001). Literacy and post-discharge follow-up were associated with greater compliance (P < 0.05 for both). Compliance was highest with anti-hypertensive drugs (98% after MI, 78% after stroke), followed by anti-platelet agents (94% after MI, 75% after stroke) and anti-lipid agents (70% after MI, 59% after stroke). Patients reported simply not feeling the need, acquiring fresh medical advice or a perceived lack of benefit, as reasons for not complying with their discharge prescriptions. CONCLUSIONS Although similar drugs are involved, compliance with prescribed regimens is appreciably lower after stroke than after MI. Our findings underscore the need for better patient education regarding secondary prevention after stroke.

Alzheimer disease therapeutics: perspectives from the developing world.

Although a majority of dementia patients live in middle-income and low-income countries, dementia represents an under-recognized public health burden in the developing world. Culturally and socially, it tends to be trivialized as an inevitable consequence of aging. Economic constraints are paramount, precluding the availability of institutionalized elder care and a state-sponsored health care system. Evidence-based practice for the management of dementia is also hampered by lack of a clear-cut expert consensus on the efficacy of anti-dementia drugs. Public health education, substantial health infrastructure development, and therapeutic advances are necessary for the developing worlds looming dementia crisis to be adequately tackled.

Clinical predictors of EMG-confirmed cervical and lumbosacral radiculopathy

BACKGROUND Electromyography (EMG) for suspected cervical or lumbosacral root compression is often negative, producing expense and physical discomfort that could have been avoided. To improve patient selection for testing, we sought to identify clinical features that would accurately predict presence of radiculopathy on EMG. METHODS Adult patients consecutively evaluated for suspected cervical or lumbosacral root compression at an academic clinical neurophysiology laboratory were prospectively enrolled. Presence of clinical features suggesting root disease (neck or back pain, dermatomal pain or numbness, myotomal weakness, segmental reflex loss, and straight leg-raising) was recorded prior to testing. EMG examination to confirm root compression was conducted per standard protocols. Analysis was based on computation of sensitivity, specificity, predictive values, and accuracy. RESULTS A total of 200 patients (55% male; mean age 46.4 years; 38% suspected of cervical and 62% of lumbosacral disease) were included. EMG evidence of root disease was detected in 31% of cervical and 62% of lumbosacral referrals. Dermatomal pain was the most sensitive, and segmental reflex loss and myotomal weakness the most specific individual predictors of root disease. Combined presence of dermatomal pain or numbness with segmental reflex loss and myotomal weakness approached specificities of 78% (lumbosacral disease) and 99% (cervical disease). In all cases, myotomal weakness was the most accurate predictor of root disease. CONCLUSION The diverse symptoms and signs of cervical and lumbosacral root compression predict a positive electrodiagnosis of radiculopathy with varying degrees of accuracy, and may be used to guide patient selection for EMG testing.

Risk of multiple sclerosis after idiopathic optic neuritis in a Pakistani population.

BACKGROUND AND OBJECTIVE Optic neuritis (ON) is associated with a 38% ten-year risk of developing multiple sclerosis (MS) in Western populations, but the corresponding risk in non-Western populations is unclear. We conducted this study to estimate the risk of progression to MS after an episode of ON in a South Asian population. METHODS Two hundred and fifty-three patients with idiopathic ON were identified by reviewing records of visual evoked potentials and chart notes from a single academic center spanning the years 1990-2007. A structured telephone interview was then conducted to identify patients who had subsequently received a diagnosis of MS. The diagnosis was corroborated from chart notes, where possible. Cumulative probability of conversion to MS was calculated using Kaplan-Meier survival analysis. RESULTS The five-year risk of developing MS was 14.6% and the ten-year risk was 24%. Patients (N = 218) who had one or more typical demyelinating lesions on baseline brain magnetic resonance imaging (MRI) had a 68% 10-year risk; those with no lesions or non-typical lesions had a 14% risk (p < 0.001). Female gender, recurrent ON, and occurrence of ON in winter months were also associated with increased risk (p < or = 0.001). Severity of ON and likelihood of detecting cerebrospinal fluid (CSF) oligoclonal bands were higher in patients who developed MS. CONCLUSION Idiopathic ON in Pakistan carries a lower risk of progression to MS compared with Western data. As in Western populations, however, presence of abnormal baseline brain MRI and CSF oligoclonal bands correlate with increased MS risk.

Preparing for the next natural disaster: need for a WHO coordinating centre

This month is the first anniversary of the 7.6 Richter earthquake which struck Pakistan on 8 October 2005. The medical communitys response to this tragedy was overwhelming. In the hardest hit areas--Bagh, Balakot, Mansehra and Muzaffarabad--there were no hospitals, clinics or trauma centers within 80 km. Initial estimates suggested a death toll of 70 000 with over 150 000 injured. In the first 48 hours, 22 medical aid camps were established by local relief organizations in collaboration with the Pakistani Armed Forces in Balakot. Within 72 hours, physicians, surgeons, and nurses began pouring into other affected areas. Medical personnel of Pakistani origin working in Europe, the Middle East and the United States were among the first to arrive, followed by hundreds of doctors from Canada, across Europe, Malaysia, Turkey and the United States. In the first month, more than 1700 doctors from 23 countries came to the affected areas, either as self-motivated individuals or as part of an organized relief mission. We had no shortage of doctors or medical supplies in the affected areas; lack of coordination was our main problem. People did not know where to go and what to do. A year later, medical relief efforts remain uncoordinated. Many people brought medications and surgical supplies that were never used. There were 165 doctors available at the PIMA field hospital, Bagh, in the last week of October 2005. They all came by themselves without any coordination. In August 2006, we visited medical facilities in Balakot, Bagh, Mansehra and Muzaffarabad. There are nine active medical facilities in these areas with a combined outpatient turnover of about 3200 patients per day. These facilities still are run by volunteer doctors on two-week rotations. We saw large warehouses full of medications, injections and supplies--worth millions of dollars--that are probably never going to be used. It is gratifying to be reminded that the world is full of doctors who are driven to help people in need. Many doctors made great efforts to travel quickly to the quake-affected areas; only to be hampered by improper coordination and logistics. Most medical camps in Pakistan were equipped for trauma management and worked efficiently for the first week. After that, respiratory tract infections, diarrhoea and tetanus were the predominant complaints, for which personnel were not prepared. Cultural constraints were also problematic. Large numbers of sick women refused to be seen or examined by a male physician; proper assignment of female physicians could have made a substantial difference. Over two dozen articles have provided a well rounded situation analysis of the earthquake in Pakistan, (1-5) but it is crucial to ask how can we do better next time. We suggest that WHO should establish a coordinating centre for natural disasters, and maintain a global database of volunteer health professionals. …

PO10.19 clinical spectrum of pseudo seizures at a tertiary care hospital Karachi: a video EEG based study

Background: Cyclic vomiting syndrome (CVS) is characterized by recurrent, stereotypic episodes of incapacitating nausea, vomiting, and other symptoms, separated by intervals of comparative wellness. The second edition of the International Headache Classification classifies CVS as the subgroup of childhood periodic syndromes, which are common precursors of migraine. CVS may respond to migrainedirected prophylactic agents such as beta-blockers, amitriptyline, and cyproheptadine. Since 1988, valproate has been prescribed for migraine prophylaxis. The aim of this therapeutic trial was to evaluate the use of valproate, an antimigraine prophylactic drug, for the prophylactic management of CVS in children. We used prophylactic therapy in patients in whom the episodes of CVS occurred more-than-once a month and/or who particularly has severe and disabling episodes. Methods: The nature of the trial and the possible side effects of the drug were explained to the prospective participants, i.e., parents as well as patients. After receiving an informed consent, 13 children diagnosed with severe CVS were enrolled in the study. Prophylactic therapy consisted of valproate administered at a dose of 10 40 mg. All patients underwent diagnostic tests to rule out organic causes of their symptoms. Vomiting was severe enough in all patients to cause dehydration requiring hospitalization for intravenous rehydration. Electroencephalogram (EEG) showed spikes or spike-wave complexes in two patients, and normal EEG in the remaining patients. Nine of the 13 patients did not respond to medical therapies such as propranolol, amitriptyline, cyproheptadine, phenobarbital, phenytoin, and carbamazepine. Three patients required combination therapy with valproate and phenobarbital. Results: Of the 13 patients, two showed complete resolution of their symptoms; nine showed marked improvement, which was evidenced by a low number of attacks with reduced severity; and two failed to respond to valproate therapy. Four patients experienced relapse with a decreased dosage of valproate. Side effects associated with long-term valproate administration were not observed, with the exception of mild liver dysfunction. Conclusions: Valproate appears to be effective for the prophylactic management of severe CVS, with 85% of all patients achieving a reduction in the frequency of attacks.

PO5.53 critical illness polyneuropathy and myopathy: experience at a tertiary care center in Pakistan

Background: CIDP is a progressive or relapsing immune mediated disorder often responsive to corticosetereroids, IV immunoglobulin & plasma exchange. Hepatitis C is common cause of death in patient having chronic hepatic disorder & affecting approx. 1 out of 10 20 population of Pakistan. Hepatitis C may be associated with peripheral neuropathies mainly axonal, chronic as well as acute cryoglobulinemia, and association with CIDP is less commonly explained. To date the optimal antiviral treatment of Hepatitis C viral infection is the combination of peg interferon-a with ribavarin. Case report: 44 years old, male with hepatitis C associated CIDP improved with combination of antiviral therapy like interferon-a and Ribavarin. Five weeks after starting therapy he felt 80% improvement in symptoms (muscle power & numbness). Viral eradication was confirmed (HCV PCR negative) after treatment patient became symptoms free. Repeat NCS/EMG turned to be normal except absent bilateral H-reflex (possibly secondary to underlying diabetes mellitus. Conclusions: We described a patient with hepatitis C associated CIDP that markedly improved with the antiviral therapy. The current case report may be an initiative to do more studies in the different canters, particularly in countries where HCV-infection is more common, like in our country Pakistan.

Is cricket the magic glue that unites South Asia

In South Asia, cricket has come to bear the promise of delivering lasting peace to a region tormented by a half century of strife. It may seem flippant to suggest that a sport will accomplish this when almost all else has failed, but consider the following. Mounting enmity between India and Pakistan is threatening to devour the entire region. Decades of failed diplomacy testify to the futility of conventional peace moves, and intransigent foreign policy positions bring the two neighbours ever closer to a nuclear flashpoint. India and Pakistan may speak the same language, but their deadlock cries out for a new medium of communication. Like marmalade, tweed jackets, and other things English, cricket is an acquired taste, which makes it slow to pick up but impossible to let go of. Introduced to the subcontinent in the 1800s, by the 1920s it was commanding great popularity in colonial India. In 1932 India became a Test playing country and, five years after the partition of 1947, Pakistan followed suit. In a cheerless, gloomy existence towards …