Childhood epilepsy.

OBJECTIVE: To determine the community-based prevalence of childhood epilepsy and its treatment gap in rural and urban population in Punjab, Pakistan. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Gujranwala District, from March to June 2007. METHODOLOGY: Ten out of 52 Union Councils of District Gujranwala, Pakistan, were randomly selected. Field officers, specifically trained for screening children with active epilepsy, performed a door-to-door survey in the selected Union Councils using area vaccinators as key informants. Final confirmation of active epilepsy and treatment details were ascertained by a qualified paediatrician and a paediatric neurologist, where required. Treatment gap was defined as relative (when treated inappropriately) and complete (complete lack of treatment). RESULTS: Among a total, under 16 years population of 92254, prevalence of childhood epilepsy was found to be 7.0/1000 (n=643) with similar distribution between urban and rural residents. Up to 66% (n=424) patients were being managed by an unqualified person including paramedics and faith healers. Treatment gap was found in 88% (n=566) patients. CONCLUSION: Childhood epilepsy is common in both urban and rural areas of District Gujranwala. Area vaccinators may be incorporated into screening and referral program to bridge the treatment gap utilizing minimum available resources.

Predictors of clinical course of subacute sclerosing panencephalitis: experience at the Children's Hospital, Lahore.

OBJECTIVE: To determine the clinical course of Subacute Sclerosing Panencephalitis (SSPE) and different factors affecting the clinical course. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Children's Hospital, Lahore, from October 2005 to May 2008. METHODOLOGY: All serologically confirmed patients of SSPE were registered and clinical staging of these patients were done from stage-I to stage-IV. Clinical course of these patients was classified by using neurological disability index as fulminant, acute, subacute, and chronic course. Clinical course was analyzed for any difference with age, gender, immunization for measles, measles infection, nutritional status and correlation with age of onset of SSPE, (Spearman's correlation), using statistic package for social science (SPSS) V. 14. RESULTS: A total of 57 cases (41 males, 16 females) with mean age of 7.45 years were studied. Forty (71.4%) of them were vaccinated with single dose at about 9 months of age, 41% (23/57) had measles infections ≤ 2 years of age. Using the Neurology Disability Index for these patients 10.5% had fulminant, 17.5% had acute, 49.2% subacute and 22.8% had chronic course. Age, gender, age at measles infection, SSPE onset age and nutritional status were poor predictors of clinical course of SSPE. Unvaccinated patients showed significantly more rapid course of disease (p = 0.04). CONCLUSION: Clinical course of SSPE cannot be predicted at the onset of this catastrophic disorder. Children not immunized against measles had a significant rapid course of disease.

Predictors of intractable childhood epilepsy.

OBJECTIVE: To determine the prognosis of seizures in epileptic children and identify early predictors of intractable childhood epilepsy. STUDY DESIGN: Case-control study. PLACE AND DURATION OF STUDY: The Epilepsy Centre of the Children's Hospital Lahore, from February 2005 to April 2007. PATIENTS AND METHODS: All children (aged 1 month to 16 years) with idiopathic or cryptogenic epilepsy who were treated and followed at the centre during the study period were included. The patients who had marked seizures even after two years of adequate treatment were labeled as intractable epileptics (cases). Children who had no seizure for more than one year at last follow-up visit were the controls. Adequate treatment was described as using at least three anti-epileptic agents either alone or in combination with proper compliance and dosage. Records of these patients were reviewed to identify the variables that may be associated with seizure intractability. RESULTS: Of 442 epileptic children, 325 (74%) intractable and 117 (26%) control epileptics were included in the study. Male gender (OR=3.92), seizures onset in infancy (OR=5.27), = 10 seizures before starting treatment (OR=3.76), myoclonic seizures (OR=1.37), neonatal seizures (OR=3.69), abnormal EEG (OR=7.28) and cryptogenic epilepsy (OR=9.69) and head trauma (OR=4.07) were the factors associated with intractable epilepsy. Seizure onset between 5-7 years of age, idiopathic epilepsy, and absence seizures were associated with favourable prognosis in childhood epilepsy. CONCLUSION: Intractable childhood epilepsy is expected if certain risk factors such as type, age of onset, gender and cause of epilepsy are found. Early referral of such patients to the specialized centres is recommended for prompt and optimal management.

Iron Oxide NPs Facilitated a Smart Building Composite for Heavy-Metal Removal and Dye Degradation.

Due to the growing population, drought, and the contamination of conventional water sources, the need for clean water is rising worldwide with high demand. The application of nanomaterials for water purification can provide a better water quality, by eliminating toxic metals and also decomposing organic contaminants. Exploitation of industrial coal-burned byproduct, fly ash, through nanomodification has been developed in this exertion for the treatment of wastewater along with heavy-metal remediation and dye degradation. The fly ash was sintered at 1000 °C with addition of hydrothermally synthesized iron oxide nanoparticles to make a cementitious composite (FA10C) using an alkali activator (NaOH + Na2SiO3) at ambient temperature. Chemical investigations of the fly ash and the FA10C composites were done by X-ray fluorescence techniques. Analysis of FA10C by X-ray diffraction, Fourier transform infrared, field emission scanning electron microscopy, energy-dispersive spectrometry, and dynamic thermal analysis/thermogravimetric techniques revealed that nanodimensioned rod-shaped mullite formation and its interlocking textures enhance the strength of the building composite. Furthermore, the cementitious composite (FA10C) has been used as an adsorbent to remove heavy metals (lead, chromium, cadmium, copper) and carcinogenic dyes (methylene blue, Congo red, and acid red-1) from their aqueous solutions. The mineralogical features of the composite FA10C and its adsorption capacities/efficiencies were studied by systematic investigation of different parameters, and the adsorption data have been analyzed using Langmuir isotherm. The experimental findings suggest that the iron oxide nanoparticles facilitated fly ash can be implemented as a substitute cementitious composite (greenhouse effect) in construction technology being an energy-saving, low cost, and eco-friendly process in adsorbent manufacturing.

Neurofibromatosis type II: a rare neurocutaneous syndrome.

Neurocutaneous syndromes are heterogeneous group of disorders with abnormalities of central as well as peripheral nervous system. Neurofibromatosis type II (NF-II) is an autosomal dominant neurocutaneous syndrome rarely diagnosed in pediatric population. Diagnosis is based on clinical history and radioimaging. We present a 14 years old boy with headache and decreased hearing, who turned to be a case of neurofibromatosis type II.

Clinical spectrum of infantile spasm at presentation.

OBJECTIVE: To determine the clinical and EEG findings in children with infantile spasms at their initial presentation to the Neurophysiology Department, Children's Hospital, Lahore, Pakistan. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Neurophysiology Department, Children's Hospital, Lahore, Pakistan, from January 2008 to December 2010. METHODOLOGY: Children aged < 24 months, referred for their first EEG test was assessed for the diagnosis of infantile spasms. Clinical manifestation, EEG finding and anti-epileptic drugs being administered on presentation were analyzed by the paediatric neurologists. RESULTS: Among the total 2050, 410 children (20%) had infantile spasms. Mean age at presentation was 4.6 + 3.5 months. Three hundred and twenty eight presented due to infantile spasms / seizures (80%) and 82 due to psychomotor delay / regression (20%). Seventy-two percent patients presented at the age < 6 month and no patient presented after the age of 18 months. Spasm types were mixed (56%), flexors (24%), extensor (12%) and asymmetric (8%). Etiology classification was symptomatic in 58% and cryptogenic in 42%. Autonomic disturbance, impaired consciousness and abnormal eye movements were the dominant initial clinical presentations. EEG records showed hypsarrhythmic/modified hypsarrhythmic in 82% and other forms of epileptic discharges in 18%. Hormonal therapy was being administered in 12%, 40% were receiving Phenobarbitone and 34% were not being treated with any anti-epileptic agent. CONCLUSION: Patients with infantile spasms have abnormal EEG findings predominantly the hypsarrhythmic modified hypsarrhythmic discharge. To avoid improper treatment, such patients should be referred to the specialized centres.

Ventilator-associated pneumonia in children.

OBJECTIVE: To determine the frequency of Ventilator-Associated Pneumonia (VAP) and to identify the associated factors, causative organisms and outcome of VAP in children admitted to ICU. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Medical ICU (MICU) of the Children's Hospital and Institute of Child Health, Lahore, from August 2008 to March 2009. METHODOLOGY: All children admitted to MICU and requiring ventilation during the study period were included and monitored for any features suggestive of VAP. Partial septic screen was done in all suspected cases. VAP was labelled when any patient on the ventilator for more than 48 hours had at least 2 of the following features of nosocomial infection - fever > 101°F, TLC < 4000 or > 15000 per mm3, neutrophils > 85%, CRP > 48 mg/L or new findings on chest examination suggestive of pneumonia; and radiological evidence of new or progressive and persistent infiltrates. Percentages were compared using chi-square test with the significance at p-value less than 0.05. RESULTS: Of the 93 children requiring mechanical ventilation during the study period, 16 developed VAP (17%). Almost half (46%) were younger than 1 year with male to female ratio of 1.2:1. Children developing VAP required ventilation for 13.5 (+ 10.1) days compared to 7.7 (+ 5.5) days in those who did not develop VAP. The common organisms isolated were Pseudomonas, Klebsiella and E. coli. Factors associated with increased frequency of VAP included age less than 1 year, unplanned emergency intubation and use of continuous intravenous sedation. Features that strongly suggested underlying VAP included purulent tracheal secretions compared to increased secretions alone, CRP > 48 mg/L, positive radiological findings and positive tracheal aspirate culture. Overall mortality was 23% among the ventilated cohort. Thirty two percent of them had VAP compared to only 13% among those who survived to discharge (p = 0.03). CONCLUSION: The frequency of VAP was 17% in this series. Factors significantly associated with VAP were age less than 1 year, unplanned intubation and continuous sedation. The important predictors of VAP included purulent tracheal secretions, high CRP and persistent new radiological findings.

Childhood primary angiitis of the central nervous system.

OBJECTIVE: To analyze the clinical course and magnetic resonance angiographic (MRA) abnormalities in children with primary angiitis of the central nervous system (cPACNS). STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Neurosciences and Neuroradiology Department of the Children's Hospital, Lahore, from January 2009 to December 2010. METHODOLOGY: The cohort comprised consecutive patients diagnosed as having cPACNS based on clinical findings and identification of arterial stenosis on magnetic resonance angiography (MRA) in the absence of an underlying condition that could cause these findings. The treatment protocol for ischaemic infarcts consisted of induction therapy with intravenous steroids pulses and intravenous immunoglobulin followed by maintenance therapy with azathioprine and low dose aspirin. When indicated, they were treated with anticoagulants at least for 4 weeks along with induction therapy. Patients were followed at a single centre and systemically assessed for clinical presentation, classification of disease as progressive or non-progressive, adverse effects of anticoagulants, aspirin, azathioprine and their hospital course. RESULTS: Sixty-eight children with medium-large vessel cPACNS (62% boys, 38% girls) with mean age of 8.5 ± 3.5 years were enrolled in this study. Motor deficit (70%); headache (64%) and fever (20%) were the commonest symptoms; whereas hemiparesis (60%); seizures 55% (focal 35%, generalized 20%) and decreased conscious level (30%), were the commonest neurological findings. Neuroradiological findings were ischaemic strokes in 50 (73.5%), haemorrhagic strokes in 10 (14.7%) and ischaemic haemorrhagic lesions in 8 cases (11.8%). Angiographically 51 (51/68, 75%) of the cohort had non-progressive (obliterative) and 17 (17/68, 25%) had evidence of progressive arteriopathy at the time of admission. No secondary haemorrhagic lesions were documented among infarcts strokes, which were treated with heparin and oral anticoagulants. Outcome was survival in 56 cases (81.5%) and death in 12 cases (18.5%). All survivors were discharged on long-term oral aspirin; 15 of them were also commenced on azathioprine. Neurological findings among the 56 survivors were; normal 20%, minor disabilities in 25%, moderate disabilities in 20% and severe disabilities in 35%. CONCLUSION: The spectrum of cPACNS includes both progressive and non-progressive forms with significant morbidity and mortality. This treatment protocol of immunosuppressive therapy may improve long-term neurological outcome in children with medium-large vessel childhood primary angiitis of the CNS.