Migraine and the Risk of Suicide.

Rarely and tragically, migraineurs commit suicide or overdose on medications we prescribe.

Ischemic and Hemorrhagic Strokes due to Eosinophilic Granulomatosis with Polyangiitis.

BACKGROUND: We report a case of ischemic and hemorrhagic strokes occurring almost simultaneously in a patient diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) previously known as Churg-Strauss vasculitis. To our knowledge, this is the first known case. METHODS: A 59-year-old man presented with a 2-month history of bilateral leg weakness, difficulty ambulating, and dyesthesias. While in the hospital, he developed acute right hand weakness, and magnetic resonance imaging of the brain revealed multiple, bilateral ischemic infarcts. After a few days, he acutely became unresponsive and was found to have a large left frontal hematoma and underwent emergent hematoma evacuation. His weakness was unexplained by the infarcts based on location and so a peripheral process was suspected. RESULTS: Nerve conduction studies showed severe axonal sensorimotor neuropathy. A sural nerve biopsy showed necrotizing vasculitis, consistent with EGPA. CONCLUSIONS: EGPA is the rarest of the antineutrophilic cytoplasmic antibody vasculitides. The peripheral nervous system is frequently involved, but the central nervous system can also be affected. The vasculitis damages the vessel walls, which leads either to stenosis or to dilatation, resulting in ischemic or bleeding consequences which can occur simultaneously, such as in this case. Caution should be exercised when prescribing antiplatelet therapy to such patients.

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

PURPOSE: The 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 METHODS: This is a cross-sectional survey using a pre-validated, interviewer-administered questionnaire conducted at the Aga Khan University Hospital. All healthy individuals above 18 years of age attending a seminar were included as participants after consent. RESULTS: The 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 >27.5 kg/m(2) was found to be more prevalent in high-risk individuals. CONCLUSIONS: A significant proportion of the population is at high risk for obstructive sleep apnea syndrome.

Awareness of stroke risk factors, signs and treatment in a Pakistani population.

OBJECTIVE: To assess the level of awareness in the general public on risk factors, symptomatology and immediate treatment of stroke. METHOD: A cross sectional study was conducted in a sample of subjects visiting a tertiary care university hospital by means of a self-designed questionnaire. The study period extended between May and June, 2007. RESULTS: A total of 398 individuals were surveyed. Hypertension (69.1%) and stress (55.8%) were identified as two major risk factors for stroke. Among them 50.8% identified "Brain" as the principal organ involved in stroke out of which 78.2% of the response came from people whose level of education was intermediate-and-above. Around 13% of the study respondents did not know of any risk factor for stroke, while 11.6% of the study respondents didn't know about the alarming signs of stroke. The most frequent response (26.16%) to immediate management of stroke was to take the individual to Emergency Department/hospital. In all 56% reported that basic information about stroke was given to them by friend/relative. CONCLUSIONS: The overall awareness of the study population regarding stroke was shown to be inadequate by this study. Knowledge was significantly greater in participants of younger age and a higher level of education.

Identifying people at high risk for developing sleep apnea syndrome (SAS): a cross-sectional study in a Pakistani population.

BACKGROUND: Obstructive Sleep Apnea (OSA) is associated with many cardiovascular and psychiatric diseases. Day-time sleepiness is a common consequence of sleep apnea and correlates with road-traffic accidents (RTA). Pakistan has a high prevalence of factors which predispose an individual to OSA and death from RTAs are a huge burden. However there is a dearth of prevalence studies in this regard. We aim to understand local relevance of the disease and estimate the prevalence of individuals high-risk for OSA. METHODS: This cross-sectional survey was conducted among 450 individuals at Aga Khan University Hospital (AKUH), which is a tertiary care teaching hospital in Pakistan. We used the BQ as our measurement tool. Based on the responses, participants were grouped into high or low-risk for OSA. RESULTS: Our study sample size was 418 with 63.2% males. Mean age of our study population was 30.4 SD+/-12.3 years; and mean BMI was 23.2 SD+/-5 kg/m2. Out of the total sample size 24.9% reported snoring and there were twice as many males who snored as compared to females. Forty-five individuals reported that they had nodded off to sleep while driving at least once in their lifetime. On the other hand, the highest proportion of high risk individuals 47.6% was found in the age group 60 or above. The overall prevalence of individuals who were high risk for sleep apnea was 10%. CONCLUSION: A significant proportion of the population is at high-risk for OSA. Our study shows that despite low BMI and favorable craniofacial anatomy sleep apnea is still a locally relevant disease. Given the local relevance of OSAS, it is important to increase awareness among general population but more importantly among physicians of the developing countries, like Pakistan, about common clinical features and pertinent risk factors and complications of OSAS.

Attitudes toward suicide bombing in Pakistan.

Although suicide bombing is a historical phenomenon, there has been a recent upsurge in such incidents. In Pakistan, over the last year, more than 1,000 people have been killed in suicide bombing incidents. Assessing the attitudes and perceptions of people toward suicide bombing can help understand some of the root causes of this phenomenon. In this pilot study, we conducted a cross-sectional survey of people (N = 215) in Karachi, Pakistan, to assess their attitudes and perceptions toward suicide bombing. The majority of the respondents condemned suicide bombing and disagreed with the notion that Islam or any other religion supports it. Belonging to the Sunni Muslim sect and strong adherence to religion predicted support for suicide bombing. The majority believed suicide bombing to be a result of religious fundamentalism. Opinion was divided as to whether suicide bombers have an underlying psychiatric illness. Further studies with larger sample sizes are needed to determine the attitudes and perceptions of the Pakistani population regarding this important issue.

Factors associated with non-adherence among psychiatric patients at a tertiary care hospital, Karachi, Pakistan: a questionnaire based cross-sectional study.

OBJECTIVE: To elucidate predictors of non-adherence among psychiatric patients presenting at a tertiary care hospital of Pakistan, for follow-up with consultant psychiatrist. METHODS: A convenient sampleof psychiatric patients from Aga Khan University Hospital was enrolled between April and May, 2005. An interviewer assisted, standardized questionnaire was used for data collection. Patients with cognitive deficit or psychosis and those presenting for the first time were not included in the study. RESULTS: Out of 128 patients, those with co-morbidity (32.81%) were less adherent than those without comorbidity (p-value:0.002). Adherence among depressed was 61.53%; psychotic was 58.82%; bipolar disorder was 73.91%. Reasons for non-adherence included sedation (30%), medication cost (22%), forgot to take medication (36%); and inability of the physicians to explain timing and dose (92%) or benefit of medication (76%). CONCLUSIONS: Non-adherence is a common and important issue. Treatment cost and co-morbidity should be reviewed in order to keep the medication regime affordable and comprehensible.

Novel mutation in the PANK2 gene leads to pantothenate kinase-associated neurodegeneration in a Pakistani family.

Pantothenate kinase-associated neurodegeneration is an autosomal-recessive disorder associated with the accumulation of iron in the basal ganglia. The disease presents with dystonia, rigidity, and gait impairment, leading to restriction of activities and loss of ambulation. The disorder is caused by defective iron metabolism associated with mutations in the PANK2 gene, which codes for the pantothenate kinase enzyme. We report on a mutation screen conducted in two siblings to establish a molecular diagnosis of the disease and a genetic test for the family.

Combination of Radiotherapy and Targeted Agents in Brain Metastasis: An Update.

OPINION STATEMENT: The combination of radiation therapy and targeted agents (molecular inhibitors or immunotherapy) represents an opportunity to improve the outcomes of patients with brain metastases. The combination of whole-brain radiation therapy (WBRT) with targeted agents takes advantage of radiosensitization, while the combination with stereotactic radiosurgery (SRS) may allow one to substitute an effective systemic agent for adjuvant WBRT, the historical standard of care. This strategy may in turn allow the promotion of secondary prevention paradigms with possibly less cognitive toxicity. At present, the combination of targeted therapy with SRS rather than with WBRT is the more viable option although both avenues will likely have a role in the future management of brain metastases. Patients should be encouraged to enter clinical trials since the off-study use of these combinations will delay the advancement of the field. Caution is advised in the combination of radiation and targeted agents as unexpected toxicities can occur. Clinicians should avail themselves of clinical trials in order to offer patients these promising options and to move the field forward. In the absence of a clinical trial, we recommend the combination of SRS with targeted agents and deferred WBRT. Small, asymptomatic brain metastases may be best managed with single-modality targeted agents with deferred radiation therapy, preferably on a clinical trial. Advances in targeted therapies combined with radiation therapy will most likely improve local control and hopefully the quality of life and survival of patients with brain metastasis.

Missed opportunities in surveillance and screening systems to detect developmental delay: A developing country perspective.

The future of human societies depends on children being able to achieve their optimal physical and psychological development. Developmental delay is failure to acquire age-appropriate functionality. It may involve one or more streams of development. Responsive parenting has potential to promote better development. Primary health physicians are in the best arrangement to provide this assistance as they can monitor child's development longitudinally and understand the child's developmental trajectory better. Current strategy employed by majority of primary-care providers to monitor the trajectory is termed 'developmental surveillance'. It is "a flexible, continuous process whereby knowledgeable professionals perform skilled observations of children during the provision of health care". Age-appropriate developmental checklists are also used to record milestones as part of surveillance. Both, the American Academy of Pediatrics and the British Joint Working Party on Child Health Services, recommend developmental surveillance by physicians as a method of identification of developmental delays. Developmental screening, however, improves the accuracy of identifying children with delay, compared with surveillance. Primary health physicians should consider using developmental screening tools that are standardized, reliable, valid and practical in the office setting, be familiar with screening techniques which should be incorporated into ongoing care, and keep abreast of current literature. Pakistan, as a developing country, needs specific strategies to ensure that we seize all the chances to detect this delay at an earlier age and introduce intervention, in order to lessen the burden of the disability on child, family and society.

Imidazole metalloporphyrins as photosensitizers for photodynamic therapy: role of molecular charge, central metal and hydroxyl radical production.

The in vitro photodynamic therapy activity of four imidazole-substituted metalloporphyrins has been studied using human (HeLa) and mouse (CT26) cancer cell lines: an anionic Zn porphyrin and a homologous series of three cationic Zn, Pd or InCl porphyrins. A dramatic difference in phototoxicity was found: Pd cationic>InCl cationic>Zn cationic>Zn anionic. HeLa cells were more susceptible than CT26 cells. Induction of apoptosis was demonstrated using a fluorescent caspase assay. The anionic Zn porphyrin localized in lysosomes while the cationic Zn porphyrin localized in lysosomes and mitochondria, as assessed by fluorescence microscopy. Studies using fluorescent probes suggested that the cationic Pd porphyrin produced more hydroxyl radicals as the reactive oxygen species. Thus, the cationic Pd porphyrin has high potential as a photosensitizer and gives insights into characteristics for improved molecular designs.