Primary leiomyosarcoma of thyroid with pulmonary metastasis: A diagnostic odyssey.

The presented primary thyroid leiomyosarcoma (TL) case report underscores the importance of recognizing and addressing the diagnostic challenges and management complexities associated with this exceedingly rare malignancy. Given the limited effective therapeutic strategies available, timely intervention, thorough diagnostics, and vigilant follow-up are paramount in managing such intricate tumors. Further research focusing on molecular-based treatment modalities is imperative to improve patient outcomes in cases of primary TL.

Non-Invasive Predictive Biomarkers for Immune-Related Adverse Events Due to Immune Checkpoint Inhibitors.

Immune-related adverse events (irAEs) are the most common complication of immune checkpoint inhibitor (ICI) therapy. With the widespread use of ICIs in patients with solid tumors, up to 40% of the patients develop irAEs within five months of treatment, and 11% develop severe irAEs requiring interventions. A predictive test for irAEs would be a crucial tool for monitoring for complications during and after ICI therapy. We performed an extensive review of potential predictive biomarkers for irAEs in patients who received ICI therapy. Currently, only thyroid-stimulating hormone is utilized in common clinical practice. This is due to the unavailability of commercial tests and unclear predictive values from various studies. Given the lack of single strong predictive biomarkers, some novel approaches using composite scores using genomic, transcriptomics, cytokine levels, or clinical parameters appear appealing. Still, these have yet to be validated and incorporated into clinical practice. Further research conducted to validate the models before implementing them into real-world settings will be of the utmost importance for irAE prediction.

Tissue characterization of benign cardiac tumors by cardiac magnetic resonance imaging, a review of core imaging protocol and benign cardiac tumors.

Generally, cardiac masses are initially suspected on routine echocardiography. Cardiac magnetic resonance (CMR) imaging is further performed to differentiate tumors from pseudo-tumors and to characterize the cardiac masses based on their appearance on T1/T2-weighted images, detection of perfusion and demonstration of gadolinium-based contrast agent uptake on early and late gadolinium enhancement images. Further evaluation of cardiac masses by CMR is critical because unnecessary surgery can be avoided by better tissue characterization. Different cardiac tissues have different T1 and T2 relaxation times, principally owing to different internal biochemical environments surrounding the protons. In CMR, the signal intensity from a particular tissue depends on its T1 and T2 relaxation times and its proton density. CMR uses this principle to differentiate between various tissue types by weighting images based on their T1 or T2 relaxation times. Generally, tumor cells are larger, edematous, and have associated inflammatory reactions. Higher free water content of the neoplastic cells and other changes in tissue composition lead to prolonged T1/T2 relaxation times and thus an inherent contrast between tumors and normal tissue exists. Overall, these biochemical changes create an environment where different cardiac masses produce different signal intensity on their T1- weighted and T2- weighted images that help to discriminate between them. In this review article, we have provided a detailed description of the core CMR imaging protocol for evaluation of cardiac masses. We have also discussed the basic features of benign cardiac tumors as well as the role of CMR in evaluation and further tissue characterization of these tumors.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019.

INTRODUCTION: Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension. METHODS: We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence. RESULTS: We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02). CONCLUSION: Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Modelling the impact of climate change on dengue outbreaks and future spatiotemporal shift in Pakistan.

Climate change has a significant impact on the intensity and spread of dengue outbreaks. The objective of this study is to assess the number of dengue transmission suitable days (DTSD) in Pakistan for the baseline (1976-2005) and future (2006-2035, 2041-2070, and 2071-2099) periods under Representative Concentration Pathway (RCP4.5 and RCP8.5) scenarios. Moreover, potential spatiotemporal shift and future hotspots of DTSD due to climate change were also identified. The analysis is based on fourteen CMIP5 models that have been downscaled and bias-corrected with quantile delta mapping technique, which addresses data stationarity constraints while preserving future climate signal. The results show a higher DTSD during the monsoon season in the baseline in the study area except for Sindh (SN) and South Punjab (SP). In future periods, there is a temporal shift (extension) towards pre- and post-monsoon. During the baseline period, the top ten hotspot cities with a higher frequency of DTSD are Karachi, Hyderabad, Sialkot, Jhelum, Lahore, Islamabad, Balakot, Peshawar, Kohat, and Faisalabad. However, as a result of climate change, there is an elevation-dependent shift in DTSD to high-altitude cities, e.g. in the 2020s, Kotli, Muzaffarabad, and Drosh; in the 2050s, Garhi Dopatta, Quetta, and Zhob; and in the 2080s, Chitral and Bunji. Karachi, Islamabad, and Balakot will remain highly vulnerable to dengue outbreaks for all the future periods of the twenty-first century. Our findings also indicate that DTSD would spread across Pakistan, particularly in areas where we have never seen dengue infections previously. The good news is that the DTSD in current hotspot cities is projected to decrease in the future due to climate change. There is also a temporal shift in the region during the post- and pre-monsoon season, which provides suitable breeding conditions for dengue mosquitos due to freshwater; therefore, local authorities need to take adaption and mitigation actions.

Comparative effectiveness of individualized longer and standardized shorter regimens in the treatment of multidrug resistant tuberculosis in a high burden country.

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9-12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month. Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients' data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of "cured" and "treatment completed" were grouped together as successful, whereas "death," "treatment failure," and "lost to follow-up" were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan-Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p-value < 0.05 was considered statistically significant. Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79-2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35-3.03) (p-value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group (p-value <0.001) due to high cure (79.9% vs. 70.9%, p-value = 0.006) and low death (9.9% vs. 18.3%, p-value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p-value = 0.014], whereas, patient's age of 41-60 (OR = 2.62, p-value<0.001) and >60 years (OR = 5.84, p-value<0.001), baseline body weight of 31-60 (OR = 0.36, p-value = 0.001) and >60 kg (OR = 0.23, p-value <0.001), and treatment with LTR (OR = 1.88, p-value = 0.001) had statistically significant association with unsuccessful treatment outcomes. Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

Geographic accessibility to childhood tuberculosis care in Pakistan.

BACKGROUND: Tuberculosis (TB) in children is difficult to detect and often needs specialists to diagnose; the health system is supposed to refer to higher level of health care when diagnosis is not settled in a sick child. In Pakistan, the primary health care level can usually not diagnose childhood TB and will refer to a paediatricians working at a secondary or tertiary care hospital. We aimed to determine the health services access to child TB services in Pakistan. OBJECTIVE: We aimed to determine the geographical access to child TB services in Pakistan. METHOD: We used geospatial analysis to calculate the distance from the nearest public health facility to settlements, using qGIS, as well as population living within the World Health Organization's (WHO) recommended 5-km distance. RESULT: At primary health care level, 14.1% of facilities report child TB cases to national tuberculosis program and 74% of the population had geographical access to general primary health care within 5-km radius. To secondary- and tertiary-level health care, 33.5% of the population had geographical access within 5-km radius. The average distance from a facility for diagnosis of childhood TB was 26.3 km from all settlement to the nearest child TB sites. The population of one province (Balochistan) had longer distances to health care services. CONCLUSION: With fairly good coverage of primary health care but lower coverage of specialist care for childhood TB, the health system depends heavily on a good referral system from the communities.

Are patients with pulmonary tuberculosis identified by active and by passive case detection different? A cross-sectional study in Pakistan.

OBJECTIVES: Our objective was to compare the characteristics of patients with pulmonary tuberculosis (TB) identified through "extended contact screening" (ECS) with those of patients identified through routine passive case finding (PCF). METHODS: Active TB case finding by ECS was tested from 2013-2015. This was a cross-sectional study based on data collected from ECS and routine program data from Lahore, Faisalabad, and Rawalpindi districts, and Islamabad in 2015. Characteristics of patients identified through ECS and PCF were compared. RESULTS: Of the 12,114 patients with pulmonary TB in the study, 4604 (38%) were identified through ECS, of whom 4052 (88%) had bacteriological confirmation. Male patients comprised 56.2% (95% confidence interval [CI] 54.8-57.6) of patients with pulmonary TB identified through ECS and 49.7% (95% CI 48.6-50.8) of those identified through PCF. The proportion of bacteriologically confirmed cases was 88.0% (95% CI 87.1-88.9) in the ECS group and 50.3% (95% CI 49.2-51.4) in the PCF group. By regression analysis we found that compared with patients aged 15-44 years, children aged <15 years had higher chances of being identified through ECS (adjusted odds ratio 2.69; 95% CI 2.21-3.28). There was a higher chance of cases being detected by ECS in Faisalabad (adjusted odds ratio 2.57; 95% CI 2.01-3.29) than in Islamabad. CONCLUSION: ECS identified a higher proportion of male and child patients with pulmonary TB than routine case finding; both of these groups are more often unidentified through routine TB control.

Complete heart block in patients infected with SARS-CoV-2: A case series from a developing country.

Coronavirus Disease 19 (COVID-19) has led to a global pandemic and has been the center of attention across the entire medical community. This novel virus was initially thought to affect primarily the respiratory system, but now it is evident that it has a multitude of effects on the human body. Our point of interest is to establish the effect of COVID-19 infection on the conducting system of the heart. We present a case series of four patients who developed complete heart block (CHB) shortly after being infected with COVID-19 without any previous known risk factors of complete heart block. There have only been a few previous case reports on the occurrence of CHB in COVID-19 patients highlighting the importance and the need of our case series to the literature of cardiovascular outcomes in COVID-19 patients. Our case series highlight that COVID-19 can indeed affect the conduction system of the heart and cause CHB in patients who then recovered spontaneously further elucidating the transient nature of cardiovascular effects caused by the novel virus.

A Diagnostic Dilemma of Dysphonia: A Case Report on Laryngeal Myasthenia Gravis.

An autoimmune neuromuscular junction disorder, myasthenia gravis, occurs when antibodies are produced against postsynaptic membrane acetylcholine receptors. Late-onset myasthenia gravis, a rare variant of the disease found in the elderly, has become a diagnostic challenge on account of its atypical presentation. We proffer a case of a 60-year-old man that presented with progressive dysphonia and weakening of cough, which was eventually followed by difficulty in swallowing and nasal regurgitation. Examination and laboratory workup came out unremarkable apart from a positive acetylcholine receptor antibody test, due to which a diagnosis of laryngeal myasthenia, an uncommon presentation of late-onset myasthenia gravis was made. Following treatment with pyridostigmine and prednisolone saw a relief of the active complaints. This article highlights the need for physicians to stay alert and have a high suspicion of such probability for timely diagnosis.

Can COVID-19 Cause Pancreatitis? A Rare Complication of SARS-CoV-2 Infection.

Coronavirus disease-2019 (COVID-19) emerged as a cluster of atypical pneumonia in Wuhan, China in December 2019. This disease has been declared a pandemic by the World Health Organization. COVID-19 patients mostly present with upper respiratory symptoms like dyspnea, cough and fever. Various neurological, myocardial, renal and gastrointestinal complications have been reported associated with SARS-CoV-2. Acute pancreatitis is one of the common causes of upper abdominal pain, caused by alcohol consumption, gall stones and various viruses and drugs. We present a case of a young female, who was recently diagnosed as COVID-19 and later on developed acute pancreatitis without any other risk factors.  Key Words: COVID-19, SARS-CoV-2, Acute pancreatitis.

COVID-19-induced Guillain-Barre Syndrome: A Rare Complication of SARS-CoV-2 Infection.

SARS-CoV-2 causing COVID-19 initially began in Wuhan, China and now has been declared a pandemic by the World Health Organization (WHO). In addition to respiratory symptoms, it can cause various complications ranging from neurological to myocardial injuries. Guillain-Barre Syndrome (GBS) is an acute polyradiculoneuropathy affecting more often lower limbs than upper limbs and is often related to previous infectious diseases. We, herein, describe a case of a young female who presented with typical symptoms of GBS after having COVID-19 and was later on confirmed with nerve conduction study and lumbar puncture. Key Words: COVID-19, SARS-CoV-2, Guillain-barre syndrome.

Acute Hepatitis as a Rare Presentation of COVID-19.

Coronavirus disease 2019 (COVID-19) initially emerged in Wuhan, China, in December 2019, and now it has been declared a pandemic by the World Health Organization. COVID-19 commonly presents with respiratory manifestations like fever, cough, body aches, and shortness of breath. Neurological, myocardial, renal and gastrointestinal complications secondary to SARS-CoV-2 infection have been reported in the literature. Gastrointestinal symptoms reported with COVID-19 are mostly nausea, vomiting, and diarrhea. COVID-19 can rarely present with acute hepatitis. Here, we report a case of a 45-year male who presented with signs and symptoms of acute hepatitis secondary to SARS-CoV-2 infection. Key Words: SARS-CoV-2, COVID-19, Acute hepatitis.

The Spectrum of Clinical Characteristics and Complications of Tetanus: A Retrospective Cross-Sectional Study From a Developing Nation.

Introduction While tetanus has largely been eradicated with the advent of the tetanus vaccine, its prevalence in Pakistan remains alarmingly high due to insufficient uptake of the vaccination program. The clinical presentations that the disease elicits range from mere opisthotonos to more sinister complications, including respiratory failure and death, often posing an insurmountable challenge for hospitals. Methods A retrospective cross-sectional study was conducted and analyzed the medical charts of 43 patients with a confirmed diagnosis of tetanus infection. The charts were perused for the patients' demographics, clinical characteristics, and disease outcomes. The prevalence of various clinical symptoms and complications were reported in terms of frequencies and percentages. Results The mean age of the patients hovered at 29.53 ± 16.53 years, with a range of 12 to 65 years. Of those affected, 83.7% were males while 16.3% were females. Notably, none of the infected patients had a prior history of vaccination against tetanus. Trismus was noted to be the most prevalent clinical manifestation and was found in 90.70% of the patients while paraesthesia at the site of infection, found in 6.98%, was the least prevalent. The overall mortality was noted to hover at 46.5%. Conclusion While tetanus has largely been eradicated, its prevalence in Pakistan remains alarmingly high. The complications noted in the study have implications for the country's public health system and aims to better inform the current state of the national vaccination program.

Forecasting daily new infections, deaths and recovery cases due to COVID-19 in Pakistan by using Bayesian Dynamic Linear Models.

The COVID-19 has caused the deadliest pandemic around the globe, emerged from the city of Wuhan, China by the end of 2019 and affected all continents of the world, with severe health implications and as well as financial-damage. Pakistan is also amongst the top badly effected countries in terms of casualties and financial loss due to COVID-19. By 20th March, 2021, Pakistan reported 623,135 total confirmed cases and 13,799 deaths. A state space model called 'Bayesian Dynamic Linear Model' (BDLM) was used for the forecast of daily new infections, deaths and recover cases regarding COVID-19. For the estimation of states of the models and forecasting new observations, the recursive Kalman filter was used. Twenty days ahead forecast show that the maximum number of new infections are 4,031 per day with 95% prediction interval (3,319-4,743). Death forecast shows that the maximum number of the deaths with 95% prediction interval are 81 and (67-93), respectively. Maximum daily recoveries are 3,464 with 95% prediction interval (2,887-5,423) in the next 20 days. The average number of new infections, deaths and recover cases are 3,282, 52 and 1,840, respectively, in the upcoming 20 days. As the data generation processes based on the latest data has been identified, therefore it can be updated with the availability of new data to provide latest forecast.

Pulmonary arterial hypertension post COVID-19: A sequala of SARS-CoV-2 infection?

It has been suggested that pulmonary arterial hypertension (PAH) could be a potential sequela of coronavirus disease 2019 (COVID-19) in particular in those with hypertension; however, development of PAH after the course of COVID-19 in normotensive individuals are rarely reported. Here, we report a patient who developed PAH two months post-COVID-19. The patient was a 55-year-old female and normotensive, tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), developed mild respiratory distress syndrome and necessitated continuous positive airway pressure during the treatment in the hospital. After two months discharged from the hospital with RT-PCR negative for SARS-CoV-2, the patient presented with exertional dyspnea, dry cough, fatigue and episodes of syncope during exertion. Based on clinical presentation, electrocardiography, computed tomography, and transthoracic echocardiography assessment, PAH diagnosis was made. To our knowledge, this is a rare PAH case and this highlights the possible of PAH as sequala that might present in post COVID-19 patients.

The Effect of Berberine, a Drug From Chinese Folk Medicine, on Serum and Urinary Uric Acid Levels in Rats With Hyperuricemia.

Background The principal manifestation of hyperuricemia is gout. Many drugs are in use nowadays to treat gout, but they are linked with multiple side effects. The present study observed berberine (from Chinese folk medicine) on serum and urinary uric acid levels in rats with potassium oxonate-induced hyperuricemia. Materials and methods Thirty-six adult healthy female Sprague Dawley rats were randomly divided into six groups of six rats each. To induce hyperuricemia, all the groups except Group A were given potassium oxonate (250 mg/kg) intraperitoneally on days 1, 3, and 7. Group A, the normal control group, was given normal saline for seven consecutive days intraperitoneally. Group C was administered allopurinol (5 mg/kg body weight) intraperitoneally, and Group D, E, and F were given berberine in doses of 0.75 mg/kg, 1.25 mg/kg, and 2.5 mg/kg body weight respectively intraperitoneally for seven consecutive days, one hour after the potassium oxonate injection. On zero, first, third, and seventh day of the experiment, blood and urine samples were taken to estimate the serum and urinary uric acid levels. On days zero and 7, serum uric acid was measured by cardiac puncture, while on days 1 and 3, it was measured by the tail prick method. The uric acid was measured by an enzymatic colorimetric method and creatinine by the Jaffe method. Fractional excretion of urate was also calculated. Results Berberine lowered serum uric acid levels in rats with potassium oxonate-induced hyperuricemia with highly significant results (p-value <0.001) in all three dosages. Berberine increased the urinary uric acid level and the fractional excretion of urate in a time-dependent manner in all three dosages. This effect was maximally shown by low dose berberine with a highly significant result (p-value <0.001). Conclusion Berberine successfully decreased the serum uric acid level of hyperuricemic rats by increasing the urinary uric acid level and fractional excretion of urate.

Management of Spontaneous Chylothorax in a Neonate: A Medical Challenge.

Chylothorax or collection of lymphatic fluid in the pleural space is an exceedingly rare cause of pleural effusion and respiratory distress in neonates. In adults, prompt diagnosis and effective treatment regimen can aid in the resolution of chylothorax; however, in neonates treating the condition can be an onerous challenge for the pediatricians due to the rarity and perplexing clinical presentation. We elucidate a case of spontaneous chylothorax in a 15-day-old neonate who presented to us with respiratory distress, chest indrawing, and cyanosis for nine days. The prenatal and birth history of the patient were insignificant. The detailed laboratory and radiological assessment of the patient divulged a diagnosis of spontaneous chylothorax for which the patient was intubated. Unfortunately, the patient deteriorated and eventually expired on the 23rd postnatal day due to the complications of respiratory acidosis and hypoxemia.

COVID-19-Induced Mesenteric Thrombosis.

Gastrointestinal symptoms, such as diarrhea (most common among gastrointestinal symptoms), nausea/vomiting, anorexia, abdominal pain, abnormal liver enzymes, and pancreatitis, are being increasingly recognized in patients with coronavirus disease 2019 (COVID-19). Moreover, COVID-19 has also been implicated in coagulopathy, especially in patients with severe disease. Here, we report a case of acute intestinal ischemia secondary to superior mesenteric thrombosis in a young female patient with mild COVID-19.

Early Complications of Ventriculoperitoneal Shunt in Pediatric Patients With Hydrocephalus.

Objective Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for the treatment of hydrocephalus (HDC), especially in children. However, this is prone to many complications, and requires repeated surgeries, which as such increases the morbidity of the patients. It is estimated that majority of the complications occurs in the immediate post-operative period and the rate of complications decreases over the time, with no impunity to these, though. We conducted this study to know about the complications of VPS in the early post-operative period, in pediatric patients with hydrocephalus. Materials and methods This descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, between June 2019 and January 2020 (seven months). All patients with hydrocephalus below 12 years of age, operated for the first time were included after taking an informed consent, while those with repeated shunt procedures and elderly patients requiring shunt were excluded from the study. Patients' details like age, gender, location, contact number, cause of hydrocephalus, date of shunt placement, type of surgery (elective or emergency) and any follow-up complications like failure, erosion, infections, ileus were noted on a predesigned proforma. After the surgery, patients were followed for a period of one month, and contacted either through the telephone or asked to visit in the outpatients on the specified days, and were evaluated for any shunt-related complications, and any of these complications suspected were further evaluated and noted. The data was analyzed using the statistical program SPSS version 19 (IBM Corp., Armonk, NY). Results are presented in the form of charts, tables and graph. Results During the study period, we evaluated a total of 151 patients; there were 78 (51.65%) males and 73 (48.34%) females with a male to female ratio approaching 1.1:1. The age range was from 22 days to 12 years. The mean age was 38.46 ± 7.53 months. The primary indications for the insertion of VP shunt were: congenital hydrocephalus in 70 (46.4%), post infectious hydrocephalus in 57 (37.7%), hydrocephalus due to tumor in 22 (14.6%), and post traumatic hydrocephalus in two (1.4%) patients. Among the total number of patients, 85 patients (55.6%) were done as elective cases and 66 patients (44.4%) were done as emergency cases. Complications were encountered in 30 patients (19.87%) during the follow-up of 30 days. Complications occurred between day 1 and day 20 of follow-up with a mean of 9.10 ± 1.69 2SD days. Conclusion VP shunt is the most widely used treatment for HDC, but is predisposed to complications and almost every fifth case of VP shunt comes across with complications. Shunt blockage, infections and abdominal wound-related complications are common earlier complications in pediatric patients with hydrocephalus.