Salman Assad

Novel and Conservative Approaches Towards Effective Management of Plantar Fasciitis

We assessed the effectiveness of the different treatments for plantar fasciitis (PF) based on the changes in functional outcomes. A systematic literature search was carried out and studies from 2010 to 2016 were included in this review. The databases from Google Scholar, PubMed and Cochrane were used for the various treatment modalities of plantar fasciitis. The objectives measured included visual analog scale (VAS), Roles and Maudsley scale, foot function index (FFI), plantar fascia thickness and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot scale as the tools to predict the improvement in symptoms of pain and discomfort. Eight randomized controlled trails that met the selection criteria were included in this review. Extracorporeal shock wave lithotripsy (ESWL) with botulinum toxin type A, corticosteroid injections, autologous whole blood and plasma treatment, novel treatments like cryopreserved human amniotic membrane, effect of placebo, platelet rich plasma injections and corticosteroid injections, physiotherapy and high strength training were analyzed. All the treatment modalities applied did lead to the reduction in pain scores, but for long term management autologous condition plasma and platelet rich plasma are the preferred treatment options. Impact of physiotherapy and high strength training is equivalent to corticosteroid injections and hence is suited for patients avoiding invasive forms of treatment.

Importance of Mean Red Cell Distribution Width in Hypertensive Patients

Purpose Red cell distribution width (RDW), expressed in femtoliters (fl), is a measure of the variation in the size of circulating erythrocytes and is often expressed as a direct measurement of the width of the distribution. We aim to observe the mean value of red cell distribution width (RDW) in hypertensive patients. Increased RDW can be used as a tool for early diagnosis, as an inflammatory marker, and a mortality indicator in hypertensive patients due to its close relation to inflammation. Materials and methodology Hypertensive patients who had the condition for more than one year duration, diagnosed according to the Joint National Committee (JNC 7) criteria were subjected to complete blood count and RDW measurement. One hundred patients, aged between 12 years and 65 years were enrolled from the outpatient department of medicine at the Military Hospital Rawalpindi. Results The mean age (± SD) of the patients was 51.48 ± 10.08 years. Out of 100 patients 69% were males whereas 31% were females. The overall frequency of hypertension more than five years was 55% subjects whereas 45% individuals had duration of hypertension less than five years. Mean RDW in females was found to be 49.35±8.42 fl while mean RDW in males was 44.78±7.11 fl. An independent sample t-test was applied to assess if there was any significant difference between age and gender. No significant difference between age and gender was found (p<0.05). The Mann-Whitney test was used to assess any association of RDW with gender. RDW values in females was found to be statistically significantly higher than in males (U=603, p=0.01). Linear regression showed that mean RDW value increased with increasing age (P <0.001). Conclusions A significant number of patients with hypertension have increased levels of RDW. Therefore, it is recommended that serum RDW should be checked regularly in patients with hypertension.

Health and Islam

Health and Islam Salman Assad, Asfandyar Khan Niazi, and Shuja Assad Medical Students, Shifa College of Medicine, Islamabad, Pakistan Nawaz Sharif Medical College, Gujrat, Pakistan E-mail: niazi.asfand@gmail.com Copyright :

Functional Outcome After Decompressive Craniectomy in Patients with Dominant or Non-Dominant Malignant Middle Cerebral Infarcts

Background: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts. Methods: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria. Results: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%. Conclusion: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.

Refractory Case of Takayasu Arteritis in a Young Woman: A Clinical Challenge

Takayasu arteritis (TA) is an idiopathic chronic inflammatory vasculitis of the aorta and its main branches, which if not treated can lead to severe vascular damage and fatal vascular events. Glucocorticoids (GCs) are the mainstay of the therapy of TA but a significant proportion of patients tend to experience flare-ups when their GCs are tapered. We report a case of a 42-year-old female with TA, diagnosed according to the 1990 American College of Rheumatology Criteria for TA. Cardiovascular assessment showed normal carotid upstrokes with bilateral carotid bruits and soft right and left subclavian bruits with weak peripheral pulses. A computed tomography (CT) aortogram of the chest showed severe stenosis of bilateral subclavian arteries and mild stenosis of right and left common carotid arteries at the origin. A CT aortogram of the abdomen showed an occluded left renal artery, a very small left kidney, and mild narrowing of the abdominal aorta below the level of renal arteries. She was initially managed with GCs along with immunosuppressive therapy including methotrexate, azathioprine, and cyclophosphamide, but her disease remained active. She was then sequentially treated with inhibitor etanercept (ETN), inhibitor tocilizumab (TCZ) and monoclonal anti-CD20 antibody rituximab (RTX), and in spite of aggressive biologic therapy she continued to have active disease. To the best of our knowledge, this is the first case of refractory TA treated sequentially with three different biologic drugs.

Transitional Vertebra and Spina Bifida Occulta Related with Chronic Low Back Pain in a Young Patient

Bertolotti’s syndrome (BS) must be considered as a differential diagnosis in a young patient presenting with low back pain (LBP). We present a case of a 26-year-old male complaining of mild chronic LBP for six years, radiating to his left thigh for the past six months. He has been taking non-steroidal anti-inflammatory drugs (NSAIDs) with skeletal muscle relaxants for pain relief. The X-ray and computed tomography (CT) imagings showed congenital enlargement of the left transverse process of the fifth lumbar (L5) vertebra forming pseudo-articulation with the sacrum and unilateral pars interarticularis defect at the L4 level on the left side, respectively. He has managed with gabapentin 100 mg three times a day for his neuropathic left leg pain. On follow-up, the patient reported that his pain has improved with gabapentin and it decreased from 8/10 to 4/10 on the visual analogue scale.

Comparison of outcomes of tubed versus tubeless percutaneous nephrolithotomy in children: A single center study

Objective To evaluate and compare the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) and tubed PCNL by using small bore nephrostomy tube (12Fr) in children for the management of nephrolithiasis. Material and methods This study was a retrospective analysis of 35 children where tubed PCNL (Group 1) was done in 18, and tubeless PCNL (group 2) in 17 patients from January 2010 to December 2016. Charts were reviewed for age, mass, stone size, operative time, hospital stay and stone-free rates. These variables were compared between the two groups. SPSS version 21 was used for data analysis. The data were shown as mean±standard deviation for continuous variables. Categorical variables were presented in percentages. Results There is no difference in terms of age, stone sizes, operative times, hospital stays, stone-free rates and post-PCNL complications between the two groups (p>0.05). The mean drop in hemoglobin level was 0.7±0.1 g/dL and 1.3±0.2 g/dL in Groups 1 and 2, respectively (p=0.01). Conclusion Tubeless PCNL in children is a safe option in well selected cases.

Visual Analogue Scale and Beck Depression Inventory Assessing the Clinical Correlation of Backache with Depression

Introduction: Malignant gliomas are highly infiltrative and aggressive primary brain tumors. Achieving gross total resection (GTR) using conventional white light microsurgical technique is a challenge. Five-aminolevulinic acid (5-ALA) can be used as an adjunct for the surgery of adult malignant glioma and improves the rate of gross total resection and patient survival. The use of this method in clinical practice is relatively new in Malaysia. We evaluate the extent of malignant glioma resection under fluorescence-guided resection (FGR) using volumetric MR neuroimaging.Background: Intracerebral hemorrhage (ICH) is a significant contributor to global health-related morbidity and mortality. Due to improved recognition and treatment of atrial fibrillation by antithrombotics, there is an increase in proportion of ICH caused by warfarin and novel oral anticoagulants. However, the relationship between anticoagulation intensity and hematoma expansion remains unclear. We aimed to investigate the effects of international normalized ratio (INR) on hematoma expansion post ICH. Methods: We conducted a retrospective study of all patients hospitalized for ICH at a single institution from January 1, 2008 and August 1, 2014. Hematoma volumes on initial CT scans and repeat CT scans were analyzed by the AxBxC/2 method. Univariate analysis was used to compare baseline characteristics and median regression analysis was performed to estimate the effects of INR on hematoma volume changes. Results: We included 224 consecutive ICH patient. Median age (IQR) was 68.5 years (17.0), 60.3% were male, median presentation Glasgow Coma Scale (GCS) (IQR) was 14.0 (4.0), median volume (IQR) of the first CT was 11.7ml (25.6), median INR (IQR) was 1.1 (0.2). We showed that INR and time lapsed between first CT and second CT were independent risk factors for hematoma volume change, adjusting for baseline hematoma volume and time. Each 1.0 increase in INR was associated with hematoma volume increase by 2.4ml (p = 0.015). Conclusions: We showed that high INR was associated with hematoma growth post ICH. However, the effects of anticoagulation reversal on the attenuation of hematoma growth remain uncertain and require confirmation in future randomized controlled studies. Correspondence to: Bernard Yan, Professor, Melbourne Brain Centre, Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Victoria, Australia, Tel: +61 3 9349 2477, E-mail: bernard.yan@mh.org.au Received: March 20, 2017; Accepted: April 21, 2017; Published: April 24, 2017 Introduction Intracerebral hemorrhage (ICH) is a stroke subtype accounting for approximately 10% – 15% of all strokes [1] and has an annual incidence of approximately 25 per 100,000 [2]. The one month case fatality rate is approximately 40% and rising to 55% in 1 year [2]. The 10-year survival rate is approximately 20% to 25% [3]. The rate of functional independence after ICH at 1 year varies between 12% to 39% [2,4]. Various factors have been shown to influence outcome in ICH, including age, initial hematoma volume, hematoma expansion (HE), neurologic deficit, intraventricular extension, and infratentorial location [5]. HE is a major determinant of early deterioration and death [6], with each milliliter increase in absolute volume is associated with increasing risk of dependence by 7% [7]. In addition, approximately 10 mL increase in hematoma volume over 24 hours was strongly associated with poor outcome [5]. HE has been widely investigated as a therapeutic target in ICH given its modifiable nature [4]. Accordingly, there is interest in determining the risk of HE, and in developing strategies to reduce HE [6]. Oral anticoagulant therapy (OAC) is considered an independent predictor of mortality in patients with intracerebral hemorrhage [8], the incidence of spontaneous intracranial hemorrhage is 7 -10 times higher amongst patients on oral anticoagulation (OAC) compared with those not on anticoagulation. OAC causes 8% – 14% of all ICH [9]. However, the association between hematoma growth and anticoagulation remains unresolved [8,9]. In this study, we aimed to investigate the effects of anticoagulation intensity on hematoma expansion. We hypothesized that ICH cases with higher International normalized ratio (INR) were associated with increased hematoma expansion. Methods Study population The study protocol was approved by the human research ethics committee of the Royal Melbourne Hospital. Written informed consent was not sought as this was a retrospective analysis of data. Yang W (2017) Intracerebral haemorrhage growth is influenced by anticoagulation intensity Volume 1(2): 1-5 Neurol Disord Therap, 2017 doi: 10.15761/NDT.1000107 We confirm that patient records were de-identified prior to analysis. We identified all subjects aged ≥18 years who were hospitalized with ICH between January 1, 2008 and August 1, 2014 at this hospital. The inclusion criteria required 2 CT scans in sequence and that the time period between the first CT to the second CT scan to be less than 72 hours. All cases were extracted from the hospital prospective stroke database. Exclusion criteria were traumatic ICH, hemorrhagic transformation of cerebral infarction, ICH secondary to vascular malformation, aneurysm, vasculitis of the central nervous system, and recent endarterectomy. In addition, we excluded patients with primary intraventricular hemorrhage (IVH), and those with missing INR values or without 2 CT scans. Patient demographics and putative risk factors, including gender, age, hypertension, diabetes mellitus, atrial fibrillation, hypercholesterolemia, ischemic heart disease, previous transient ischemic attack (TIA) or stroke, and pre-admission medications were extracted from the stroke database or by a medical record chart review. Pre-admission modified Rankin Scale (mRS), Glasgow Coma Scale (GCS) at presentation, mRS at discharge, and in-hospital mortality were collected. All presentations were within 7 days of symptom onset, including inter-hospital transfers. The initial baseline brain CT scans, second CT scan and INR values were evaluated. For warfarin-related ICH patients, initial INR values obtained before anticoagulation reversal were used for the analysis. Patients were both dichotomized by warfarin use and stratified by the level of anticoagulation. Neuroimaging analyses All CT scans were reviewed and evaluated in consensus by two experienced stroke neurologists (W.Y, B.Y.) who were blinded to the patients’ clinical status. The ICH volumes were determined from available CT scans. Hematoma Volume of first CT scan (CT 1) and second CT scan (CT 2) were calculated by AxBxC/2 methods. Intraventricular blood was not included in the volume calculation. The hematoma location was categorized into lobar (with or without involvement of subcortical white matter), deep (basal ganglia, thalamus, internal capsule), cerebellum and brainstem. Location was also dichotomized into supraand infratentorial site. One initial shape classification for ICH included three categories: regular, irregular, and separated. Statistical analysis Continuous and categorical were compared using the Mann– Whitney rank-sum test and Fisher exact test as appropriate at baseline. The following factors were considered: age, hypertension, hyperlipidemia, diabetes, and ischemic heart disease. The association between the baseline INR category and hematoma volume change was investigated using median regression analysis. Statistical analyses were performed using Stata/ IC software package, version 12.0 (StataCorp, College Station, TX). All p values are 2-tailed, p <0.05 was considered significant.R we proposed and theoretically substantiated the hypothesis, which offers new approaches to treating neurodegenerative diseases of the retina and brain (Zueva, 2015). For the first time, we suggested that the impact of visual environmental cues of complex spatiotemporal structure on a person throughout his life is necessary for normal development and aging of the brain and visual system. The theory sets the link between the complexity of neural connections, nonlinear dynamics of physiological processes in the brain and the nonlinear characteristics of sensory cues. The loss in the complexity of neural networks in the retina and the brain develops in such socially relevant neurodegenerative diseases as glaucoma, diabetic retinopathy, Alzheimer’s disease, Parkinson’s disease, etc. The necessity of maintaining and strengthening of mental abilities in extreme situations and normal aging is a separate social and medical problem. The idea is to improve the scheme of neural circuits and brain’s function in normal and neurodegenerative diseases by nonlinear visual and other sensory stimuli with complex temporal structure through the reactivation of the brain plasticity. We can expect that the development of innovative non-drug technologies of impact on brain plasticity and definition of ways to manage this process will contribute to a more efficient recovery of neuronal contacts, cognitive functions, and overall functionality in patients with neurodegenerative disorders and amblyopia. The creation of devices for nonlinear sensory stimulation and the detection of mechanisms of its impact on the brain are crucial for therapeutic strategies, which can underlay of future breakthrough technologies.

Frequency of ischemic stroke subtypes based on TOAST classification in a tertiary care center in Islamabad

C meningitis is an opportunistic infection usually seen in immuno-compromised patients, but is also known to affect apparently healthy individuals.Cryptococcal meningitis is a disease with significant morbidity and mortality. Worldwide, approximately 1 million new cases of cryptococcal meningitis occur each year, resulting in 625,000 deaths. This study was undertaken to assess the profile of patients with cryptococcal meningitis in a tertiary care center of north India. Cerebrospinal fluid (CSF) samples from 5716 meningitis patients (from Jan 2007 Dec 2015) were tested by India ink preparation / antigen detection by latex agglutination test (LAT) / culture. A total of 127(2.2%) patients were positive by one or more tests for Cryptococcus neoformans. Comorbidities associated with the disease were HIV, diabetes mellitus, renal transplantation, etc. Fever and headache were the most common clinical features. Comparison of Cryptococcal antigen and india ink was done with culture for a period of 6 months and 55.6% of the samples positive by LAT showed growth of Cryptococcus on culture. Diagnostic methods such as culture and India ink are specific but less sensitive. Antigen detection by latex agglutination proved to be both sensitive and specific method for the diagnosis of cryptococcal meningitis. Early diagnosis of infection by detection of cryptococcal antigen by latex agglutination may alter the prognosis of these patients.OBJECTIVE To investigate the effects of transvenous embolization in treatment of refractory carotid-cavernous sinus fistula (CCF). METHODS Twenty-five patients of refractory CCF with 28 foci underwent transvenous embolization, femoral vein-inferior petrosal sinus approach was used in 12 of which, and femoral vein-facial vein-superior ophthalmic vein approach was used in 12 of which. The embolizing materials included controllable coils (GDC, EDC), free coil, and silk. Three to twenty-four months after the treatment angiography was conducted on 10 patients and telephone follow-up was conducted on the other 15 patients. RESULTS Immediate complete angiographic obliteration of the fistula was achieved in 20 patients. Residual shunting was left in 5 patients, 2 with pterygoid drainage and 3 with inferior petrosal sinus drainage. Headache and vomiting were the common symptoms after embolization. The angiography during follow-up showed that there were residual shunting in 4 patients, residual inferior petrosal drainage in 1 patient, and residual pterygoid drainage in 1 patient, and that no reoccurrence was found in the 6 patients with complete angiographic obliteration. The patients undergoing telephone follow-up reported that they had not any symptom. CONCLUSION Safe and effective, transvenous embolization can be the first choice after the failure in treatment of the carotid-cavernous sinus fistula.

Zika virus: Docile or deadly?

Zika virus (ZIKV) has been declared a global public health emergency by the World Health Organization (WHO). The WHO has estimated that 4 million people can be infected by ZIKV by the end of 2016 if proper preventive measures are not taken. Our search results had yielded a total of 373 articles, of which 40 articles were included for perusal. In this review, we highlight the pathogenesis of ZIKV, different modes of transmission of ZIKV, and issues related to the diagnosis of ZIKV. Serological tests have shown strong cross-reactivity of immunoglobulin M against other flaviviruses. We have also highlighted possible preventive steps that can be deployed to prevent the epidemic from getting out of hands. The article also highlights the implication of the forthcoming Summer Olympic Games in Brazil on the spread of ZIKV. With the development of its vaccine still in embryonic stages, proper preventive strategies are the need of the hour.