Predicting Gait Speed Improvement in Idiopathic Normal Pressure Hydrocephalus Patients: The Role of Evans Index and Ventricular Volume.

Objective This study aims to investigate the association between specific imaging parameters, namely, the Evans index (EI) and ventricular volume (VV), and the variation in gait speed observed in patients with idiopathic normal pressure hydrocephalus (iNPH) before and after cerebrospinal fluid (CSF) removal/lumbar drain (LD). Furthermore, it seeks to identify which imaging parameters are the most reliable predictors for significant improvements in gait speed post procedure. Methods In this retrospective analysis, the study measured the gait speed of 35 patients diagnosed with idiopathic normal pressure hydrocephalus (iNPH) before and after they underwent CSF removal. Before lumbar drain (LD), brain images were segmented to calculate the Evans index and ventricular volume. The study explored the relationship between these imaging parameters (the Evans index and ventricular volume) and the improvement in gait speed following CSF removal. Patients were divided into two categories based on the degree of improvement in gait speed, and we compared the imaging parameters between these groups. Receiver operating characteristic (ROC) curve analysis was employed to determine the optimal imaging parameter thresholds predictive of gait speed enhancement. Finally, the study assessed the predictive accuracy of these thresholds for identifying patients likely to experience improved gait speed post-LD. Results Following CSF removal/lumbar drain, the participants significantly improved in gait speed, as indicated by a paired sample t-test (p-value = 0.0017). A moderate positive correlation was observed between the imaging parameters (EI and VV) and the improvement in gait speed post-LD. Significant differences were detected between the two patient groups regarding EI, VV, and a composite score (statistical test value = 3.1, 2.8, and 2.9, respectively; p-value < 0.01). Receiver operating characteristic (ROC) curve analysis identified the optimal thresholds for the EI and VV to be 0.39 and 110.78 cm³, respectively. The classification based on these thresholds yielded significant associations between patients displaying favorable imaging parameters and those demonstrating improved gait speed post-LD, with chi-square (χ²) values of 8.5 and 7.1, respectively, and p-values < 0.01. Furthermore, these imaging parameter thresholds had a 74% accuracy rate in predicting patients who would improve post-LD. Conclusion The study demonstrates that ventricle volume and the Evans index can significantly predict gait speed improvement after lumbar drain (LD) in patients with iNPH.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context.

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis. PURPOSE: Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan. METHODS: The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE). RESULTS: The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age. CONCLUSION: The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE). The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age. The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

A rare case of post-transplant lymphoproliferative disorder (Hodgkins lymphoma) post autologous stem cell transplantation: A case report and review of literature.

Introduction: Post-transplant lymphoproliferative disorders(PTLD) include a mix of rare yet life endangering complications. Case presentation and conclusion: Here, we report a case of a 63-year-old man who was the victim of post-transplant lymphoproliferative disorder (Hodgkin's lymphoma). The patient was initially diagnosed with multiple myeloma, for which chemotherapy and the autologous stem cell transplant was carried out. Post transplant patient was stable but on a follow up visit 6 months after the transplant he presented with generalized lymphadenopathy.His subsequent workup was done including a biopsy of cervical lymph node, which revealed Classical Hodgkin's lymphoma (post-transplant lymphoproliferative disorder (PTLD)) of mixed cellularity type.The patient was started on chemotherapy and received a total of 4 cycles of Chemotherapy (ABVD) before his condition started deteriorating as chemotherapy was poorly tolerated leading to Bleomycin toxicity. The patient regrettably passed away due to an NSTEMI.