Focal Signs Research Articles

Herpes simplex virus limbic encephalitis in a Filipino man with advanced stage testicular cancer: A case report

A 66-year-old Filipino Male, Hypertensive, Diabetic, diagnosed with Advanced Testicular Cancer presented with a five day history of fever, productive cough associated with sudden onset of behavioral changes, memory lapses and disorientation. On admission, the patient was disoriented, with poor comprehension and inability to follow commands. There were no focal motor deficits or signs of meningeal irritation. Cranial CT scan and serum electrolytes were unremarkable. CBC showed leukocytosis with predominant neutrophils, chest xray revealed pneumonia. Piperacillin+ Tazobactam and Azithromycin was started On the second hospital day, he had seizures manifested as blank stares, teeth grinding, lip smacking and fidgety movement of the right hand. Electroencephalogram showed epileptiform discharges in both frontal-prefrontal and both frontal-central regions. A cranial MRI with Contrast revealed high T2W and FLAIR signal changes and edema in the mesial temporal lobes and right insula (Figure 1) and right lentiform nucleus (Figure 2). EEG and MRI findings are consistent with Limbic Encephalitis based on the diagnostic criteria by Gultekin et al.1(2014). A lumbar puncture yielded a colorless cerebrospinal fluid (CSF) with normal opening pressure, normal RBC and WBC, lymphocytic predominance (96%), elevated CSF protein and normal CSF glucose. CSF Acid Fast Bacilli (AFB), KOH and India Ink were all negative. Further CSF analysis for neuronal autoantibodies specifically Anti-NMDA, Anti- Hu and Anti- Ma2 were likewise negative. Polymerase Chain Reaction (PCR) assay for Herpes Simplex Virus was positive for HSV-1. Intravenous Acyclovir was started at 15mg/kg per day. After three weeks of antiviral therapy the patient's condition improved.

The eye is the window to the diagnosis: tuberculous meningoencephalitis with choroidal tubercle

A 65-year-old Caucasian man with type 2 diabetes mellitus presented to the emergency department with subacute altered mental status, preceded by a 2-month history of progressive weight loss, anorexia and...

Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports

ObjectiveTo describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). MethodsA systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. Results430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ± 3.2). ConclusionWe found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.

Blood-brain barrier opening with focused ultrasound in experimental models of Parkinson's disease.

Parkinson's disease has many symptomatic treatments, but there is no neuroprotective therapy currently available. The evolution of this disease is inexorably progressive, and halting or stopping the neurodegenerative process is a major unmet need. Parkinson's disease motor features at onset are typically limited to 1 body segment, that is, focal signs, and the nigrostriatal degeneration is highly asymmetrical and mainly present in the caudal putamen. Thus, clinically and neurobiologically the process is fairly limited early in its evolution. Tentatively, this would allow the possibility of intervening to halt neurodegeneration at the most vulnerable site. The recent use of new technologies such as focused ultrasound provides interesting prospects. In particular, the possibility of transiently opening the blood-brain barrier to facilitate penetrance of putative neuroprotective agents is a highly attractive approach that could be readily applied to Parkinson's disease. However, because there are currently effective treatments available (ie, dopaminergic pharmacological therapy), more experimental evidence is needed to construct a feasible and practical therapeutic approach to be tested early in the evolution of Parkinson's disease patients. In this review, we provide the current evidence for the application of blood-brain barrier opening in experimental models of Parkinson's disease and discuss its potential clinical applicability. © 2019 International Parkinson and Movement Disorder Society.

Acute ataxia in paediatric emergency departments: a multicentre Italian study

ObjectivesTo evaluate the causes and management of acute ataxia (AA) in the paediatric emergency setting and to identify clinical features predictive of an underlying clinically urgent neurological pathology (CUNP).Study designThis...

Changes in the Structure and Mechanical Properties of the Bone after Puncture Cryoablation: Experimental Study

Purpose of the study — to evaluate possible impact of cryoablation on a healthy bone and to identify probable causes of postoperative fractures.Materials and Methods. The authors performed cryoablation of the femur in the experiment on 8 mature rabbits of Soviet Chinchilla (SC) breed with a follow up for up to two months. Anitrogenous cryoprobe of 1.5 mm in diameter was introduced into the femur through a perforation hole. The bone was completely frozen up to -180°С in two cycles with continuous thermometry. Pathomorfological examinations were performed after 7 and 55 days along with assessment of bone hardness. Preparation of material stipulated sawing the bone at the fracture site along the bone axis. One half-bone was used for histological examination, and another one — for measuring mechanical properties by local pressing of a diamond indenter onto the bone at certain applied force. The distance between measurement points along the bone was 250 μm. Statistical processing included variance significance analysis using t-test.Results. The authors reported bone fractures at the site of cryodestruction in all animals in one week after the procedure. Statistical analysis of the measurements and histological examination demonstrated that freezing of the entire bone diameter up to -180°С results in its complete destruction. Strength reduction around the fracture site corresponded to the temperature distribution area in the range from -9ºС to -15ºС. However, areas of cooling below -40ºС exhibited some bone segments with normal hardness. Mosaic pattern of strength reduction is explained by microcirculation disorders. Histology confirmed thrombosis of intraosseous blood vessels in the area of cryotherapy. The first focal signs of osteomalacia emerged by the end of the first week after cryoablation. Subsequently, the bone preserved its regenerative properties, but by the end of the second month after the procedure the histogenesis was still not completed and the bone did not regain its strength.Conclusion. The authors believe that a limited number of cases, the specific features of the angioarchitecture of animal bones and their ability to produce a heavy periosteal response do not allow to apply obtained quantitative outcomes of the present study to clinical situations. However, complete freezing of the entire bone diameter inevitably results in fracture formation.

Tubercular Lesions in Brain Parenchyma

Background: Preoperative neuro-radiological features of tuberculosis involving brain lesions may mimic neoplastic lesions of brain & skull base and post operative histopathological study or response to empirical anti-tubercular therapy brings the ultimate diagnosis.
 Objective: Here we present our experience of 76 cases of cerebral and cerebellar tuberculosis that was managed surgically with anti-tubercular drugs or medical treatment alone without histopathological confirmation.
 Methodology: All cases of brain parenchymal tuberculosis confirmed histopathologically after surgery or confirmed by succesfull conservative treatment with anti-TB from January 2008 to June 2015 were included for study. Tubercular meningitis was excluded from the study. Patients underwent some form of surgery that confirmed the tuberculosis by histopathologically. Patients with suspected tubercular lesion in brain were treated empirically with antiTB. Post operative imaging was done with CT scan of brain or MRI of brain in immediate post operative period, six months after operation and 18 months after operation.
 Results: 34 patients underwent surgery to confirm the tuberculosis and 44 patients with suspected tubercular lesion in brain were treated empirically with antiTB of which 40 patients responded successfully and rest 4 patients did not responded and underwent surgical excisional biopsy. Common clinical features include features of raised ICP with focal signs and symptoms. Concurrent other systemic tuberculosis was found in three cases. One patient had history of full course anti-tubercular therapy for pulmonary tuberculosis 20 years back.
 Conclusion: In suspected TB lesions, conservative treatment without histopathological diagnosis may be adopted with ultimate same result
 Bangladesh Journal of Infectious Diseases, December 2018;5(2):45-60

Simple clinical parameters to diagnose Malaria in Outpatient Department.

Introduction: Malaria is the world's most important parasitic infection which poses major health challenges. Best estimates currently describe the annual global burden of malaria as 300-500 million cases and 1-2 million deaths. Traditionally malaria is diagnosed clinically based upon sign symptoms and clinical examination particularly in remote areas where laboratory facilities are not available. However, no universal criteria exist for clinical diagnosis of malaria and presenting features are highly variable region to region. Therefore, we planned to define the simple parameters based on clinical signs and symptoms that predict malaria without laboratory confirmation of parasitemia.
 Objective: To determine the sensitivity, specificity and positive predictive values of simple clinical parameters for the diagnosis of malaria without laboratory confirmation of parasitemia.
 Methodology: This observational study was carried out at pediatric department of Karachi Medical and Dental college and Abassi Shaheed Hospital Karachi during 15 April 2015 to 15 February 2015. Children between 6 months to 5 years, who presented with short duration of fever (less than 7 days) were included in study. The diagnosis of malaria was confirmed on identification of parasite (Plasmodium vivax or Plasmodium falciparum) in blood obtained from finger prick sample for thick and thin film. The patients were divided into two groups (+ve MP cases and -ve MP cases). Focal signs and symptoms, pallor (anemia) and splenomegaly were checked in both groups to assess the sensitivity, specificity and predictive values of these simple clinical parameters and co-related with the presence of malaria parasitemia.
 Result: Six hundred fifty-seven children were examined. One hundred (15.22%) children out of 657 had malaria confirmed while 84.78% (557 of 657) had illness other than malaria. There were 43 children (43%) with Plasmodium falciparum malaria, 47 children (47%) with Plasmodium vivax malaria and 10 (10%) with mixed infections. Three clinical parameters (No focal features, anemia & splenomegaly) were studied in all febrile patients which were divided into two groups (Malarial parasite +ve and malarial parasite -ve).
 Conclusion: Few simple clinical findings can lead to reliable clinical diagnosis of malaria with more logical use of antimalarial drugs in children.
 Key words: Malaria, Anemia, Splenomegaly.

Effect of ketotifen fumarate on experimental autoimmune orchitis and torsion of the spermatic cord.

The aim of this work was to study effects of ketotifen fumarate (KF) on prevention of tissue damage in testes of rats with experimental autoimmune orchitis (EAO) and on the contralateral testis in a model of prolonged testicular cord torsion (TCT). Rats with EAO or TCT were injected intraperitoneally once daily with KF or saline solution (vehicle group). Incidence and severity of testicular damage were evaluated by histopathology using an EAO score or a Johnsen score. Mast cells (MC) were identified by histochemistry and quantified. In EAO model, KF significantly reduced severity of histopathological testicular damage compared to rats in the vehicle group. KF also reduced the number of testicular MC compared to vehicle group. Similarly, in TCT model, multifocal damage of the contralateral testis was observed 30 days after testicular torsion characterized by sloughing of the germinal epithelium, seminiferous tubule atrophy, and interstitial edema. Focal signs of inflammation and fibrosis of seminiferous tubular walls were also observed. In contrast, sections of contralateral testis of rats injected with KF and killed 30 days after surgery showed normal histological features. A significant decrease in the number of MC was observed in rats treated with KF compared to untreated animals. In conclusion, we demonstrated that treatment with KF reduced testicular inflammatory process and MC infiltrates in both EAO and TCT models. The results suggest a promising treatment for infertile male patients with testicular pathologies associated with inflammation and germ cell loss.

Explanation of Postprocedural Fractional Flow Reserve Below 0.85.

Fractional flow reserve (FFR) after percutaneous coronary intervention is a predictor of adverse cardiovascular events during follow-up. However, the rationale for low post procedural FFR values remains often elusive based on angiographic findings alone. FFR SEARCH (Stent Evaluated at Rotterdam Cardiology Hospital) is a prospective single-center registry in which post-percutaneous coronary intervention FFR was assessed in 1000 consecutive all-comer patients. FFR measurements were performed with a microcatheter ±20 mm distal to the most distal stent edge. In 100 vessels with a post procedural FFR ≤0.85, and 20 vessels >0.85 high definition intravascular ultrasound analysis was performed. In 100 vessels with a post-percutaneous coronary intervention FFR ≤0.85, mean post procedural FFR was 0.79±0.05. Minimal lumen area was 2.19 (1.81-3.19) mm2, mean lumen area was 5.95 (5.01-7.03) mm2, and minimal stent area was 4.01 (3.09-5.21) mm2. Significant residual focal proximal lesions were found in 29% of the assessed vessels whereas, focal distal lesions were found in 30% of the vessels. Stent underexpansion and malapposition were found in 74% and 22% of vessels, respectively. Clear focal signs of luminal narrowing were found in 54% of the vessels analyzed. Although incidences of focal lesions, underexpansion, and malapposition were similar between both cohorts, minimal stent area was significantly smaller in vessels with a post-percutaneous coronary intervention FFR ≤0.85 as compared with those with an FFR >0.85. In patients with a post procedural FFR ≤0.85, intravascular ultrasound revealed focal signs of luminal narrowing in a significant number of cases.

Clinical Significance of Asymmetric Minimum Intensity Projection Images of Brain Magnetic Resonance Imaging in Children.

Background and PurposeThe susceptibility-weighted imaging form of brain MRI using minimum intensity projection (mIP) is useful for assessing traumatic brain injuries because it readily reveals deoxyhemoglobin or paramagnetic compounds. We investigated the efficacy of using this methodology in nontraumatic patients.MethodsWe retrospectively analyzed the asymmetric mIP findings in nontraumatic patients. Asymmetric mIP images were first verified visually and then using ImageJ software. We enrolled patients with a difference of >5% between hemispheres in ImageJ analysis. All patients underwent detailed history-taking and EEG, and asymmetric mIP findings were compared.ResultsThe visual analysis identified 54 pediatric patients (37 males and 17 females) with asymmetric mIP findings. Ten patients were excluded because they did not meet the ImageJ verification criteria. The 44 patients with asymmetry comprised 36 with epilepsy, 6 with headache, and 2 with cerebral infarction. Thirty-one of the 36 epileptic patients showed definite partial seizure activities in semiology, while the remaining patients did not demonstrate a history of partial seizure manifestations. The MRI findings were normal in all patients except for five with periventricular leukomalacia unrelated to seizure symptoms. There was agreement between mIP images and semiology in 29 (93.5%) of the 31 epileptic patients with focal signs, while the other 2 demonstrated discordance. Twenty (64.5%) of the 31 patients showed consistent EEG abnormalities.ConclusionsOur data suggest that asymmetric mIP findings are an excellent lateralizing indicator in pediatric patients with partial epilepsy.

Enterococcus Bacteremia

Enterococcus Bacteremia

Juvenile-onset polyneuropathy in American Staffordshire Terriers.

BackgroundThe only hereditary neurologic disorder described so far in American Staffordshire Terriers is adult‐onset cerebellar degeneration secondary to ceroid lipofuscinosis. We have seen several dogs with a newly recognized neurological disease characterized by locomotor weakness with or without respiratory signs and juvenile onset consistent with degenerative polyneuropathy of genetic origin.ObjectivesTo characterize a novel polyneuropathy in juvenile American Staffordshire Terriers.AnimalsFourteen American Staffordshire Terriers presented with clinical signs consistent with juvenile‐onset polyneuropathy at 5 veterinary hospitals between May 2005 and July 2017.MethodsCase series. Dogs were included retrospectively after a diagnosis of degenerative polyneuropathy had been confirmed by nerve biopsy. Clinical, pathological, electrophysiological, histological data, and outcome were reviewed and a pedigree analysis performed.ResultsAll dogs displayed clinical signs of neuromuscular disease with generalized motor and sensory involvement, associated with focal signs of laryngeal paralysis (10/14 dogs) and megaesophagus (1/14 dogs). Histopathological findings were consistent with degenerative polyneuropathy. Follow‐up was available for 11 dogs, and 3 dogs were euthanized shortly after diagnosis. In these 11 dogs, the disease was slowly progressive and the animals maintained good quality of life with ability to walk. Pedigree analysis was mostly consistent with an autosomal recessive mode of inheritance.Conclusions and Clinical ImportanceJuvenile polyneuropathy, associated with laryngeal paralysis, is a newly described entity in American Staffordshire Terriers, and results from degenerative neuropathy. When surgery for laryngeal paralysis is performed, lifespan may be similar to that of normal dogs even though affected dogs have locomotor disturbance.

Seizure characteristics are related to tumor pathology in children with brain tumors

ObjectivesBrain tumors are found in 1–3% of children with newly onset of seizures. Understanding the impact of seizures on pediatric brain tumors and factors between seizures and brain tumors are crucial. This study aimed to evaluate the association of pediatric brain tumors on seizure occurrence and the relationships between seizures and the diagnosis and prognosis of brain tumors. MethodsIn a cohort of 184 children with newly diagnosed brain tumors between August 2012 and September 2017, 56 patients with brain tumor-associated seizures were evaluated for their clinical characteristics, electroencephalography (EEG), tumor pathology, response to anti-epileptic drugs (AEDs) and their seizure outcome. ResultsThe prevalence of seizures in our cohort of children with brain tumors was 30.4% (n = 56/184). Supratentorial tumors were more commonly associated with seizures than were infratentorial tumors (89.3% vs. 10.7%; P < 0.01). Among patients with tumor-associated seizures, the tumors were most commonly located in the temporal lobe (32.1%), followed by the frontal (21.4%) and parietal lobes (16.1%) and other cortices. Thirty-four patients (60.7%) had benign tumor pathology and 22 patients (39.3%) had malignant tumor pathology; low grade astrocytoma (n = 15; 26.8%) was the most common histology type. Seizure onset at initial presentation was more frequently observed in the patients with benign tumors, whereas the patients with malignant tumors tended to have delayed seizure onset (P < 0.01). On EEGs, focal epileptiform discharges were more commonly seen in benign tumors, whereas focal and diffuse slow waves were most commonly associated with malignant tumors. Levetiracetam was the most commonly prescribed AED to treat brain-tumor-associated seizures. ConclusionsIn children with brain tumors, higher seizure frequency with normal neurologic examination was more prevalent in benign tumors, whereas less frequent seizures with focal weakness and signs of increased intracranial pressure were more indicative of malignancy. Delayed onset of seizures was more often observed in the children with malignant brain tumors. Seizure characteristics play an important role in relation to tumor biology and epileptogenesis in pediatric brain tumors.

T2 Mapping for Noninvasive Assessment of Interstitial Edema in Acute Cardiac Allograft Rejection in a Mouse Model of Heterotopic Heart Transplantation.

Heart transplantation (HTX) in mice is used to characterize gene-deficient mice and to test new treatment strategies. The purpose was to establish noninvasive magnetic resonance imaging techniques in mice to monitor pathophysiological changes of the allograft during rejection. Magnetic resonance imaging was performed at baseline and days 1 and 6 after isogenic (n = 10, C57BL/6) and allogenic (n = 12, C57BL/6 to BALB/c) heterotopic HTX on a 7 T small animal scanner. Respiratory- and electrocardiogram-gated multislice multi-echo spin echo sequences were acquired, and parameter maps of T2 relaxation time were generated. T2 times in septal, anterior, lateral, and posterior myocardial segments as well as global T2 times were calculated and compared between groups. At day 7 animals were sacrificed and graft pathology was assessed by semiquantitative regional analysis and correlated with magnetic resonance imaging results. Myocardial T2 relaxation time was significantly increased in allogenic (33.4 ± 0.1 ms) and isogenic cardiac grafts (31.8 ± 1.8 ms) on day 1 after HTX compared with healthy donor hearts at baseline (23.1 ± 0.3 ms, P < 0.001). Until day 6 after HTX, myocardial T2 further increased markedly in allografts but not in isografts (43.4 ± 1.9 vs 31.2 ± 1.1 ms, P < 0.001). Mean segmental T2 values as well as mean global T2 values in allogenic compared with isogenic cardiac grafts on day 6 were significantly higher (P < 0.01). Histologically, isogenic grafts were almost normal besides small focal leukocyte infiltrates and signs of interstitial edema, most likely due to ischemia reperfusion injury (histological sum score, 0.9 ± 0.4). In allogenic HTX, histology revealed severe inflammation and tissue edema representing allograft rejection with increased histological scores (5.3 ± 0.7, P < 0.001). Higher histological scores of rejection were significantly associated with increased T2 times on a segmental and a global level. We could show that T2 mapping is a suitable noninvasive imaging method to monitor global and regional HTX pathologies in experimental heart transplantation in mice. Progressive prolongation of T2 time was significantly associated with pathological signs of rejection.

Differentiating arterial ischaemic stroke from migraine in the paediatric emergency department

To estimate the strengths of association between clinical features and migraine or arterial ischaemic stroke (AIS) in children presenting to the emergency department. Eighty-four children with migraine, prospectively recruited from 2009 to 2010, were compared with 55 children with AIS, prospectively/retrospectively recruited from 2003 to 2010. Odds ratios were calculated via logistic regression to measure associations between clinical features and process-of-care factors, and migraine and AIS. Median age was 13years 5months (interquartile range 12y 11mo-13y 10mo) for migraine and 5years (interquartile range 3y 7mo-8y) for patients with AIS. All cases of AIS and 30% of migraine cases underwent neuroimaging. Over 40% of children with migraine had vomiting, numbness, or visual disturbance; other symptoms were uncommon. Fifty-five per cent had no signs on physician assessment. Weakness or speech disturbance were common in patients with AIS. Significant clinical features associated with increased odds of AIS included sudden symptom onset, weakness, seizures, speech disturbance, and ataxia, and signs of face, arm, or leg weakness, inability to walk, dysarthria, dysphasia, and altered consciousness (p<0.05). Significant features associated with decreased odds of AIS included older age, vomiting, visual, sensory, other symptoms, and absent focal signs on assessment (p<0.05). Presenting features can discriminate childhood AIS from migraine. These differences inform decisions about urgency and type of neuroimaging in children presenting to the emergency department with brain attack symptoms. Weakness, seizures, ataxia, speech, or walking difficulties are more frequent in arterial ischaemic stroke (AIS). Vomiting, visual, or sensory disturbance and absent focal signs are more frequent in migraine. Identifying features of AIS and migraine guides neuroimaging in children with brain attack symptoms.

The cervical spine can be cleared without MRI after blunt trauma:A retrospective review of a single level 1 trauma center experience over 8 years

BackgroundThe newest CT scanners provide resolution comparable to MRIs leading many to question when and whether cervical spine MRIs are warranted. MethodsAn 8 year retrospective review identified 241 patients who underwent CT scan and MRI of the cervical spine. The initial clinical examination, cervical spine CT scan, and cervical spine MRI were compared to identify cervical spine injuries that would have been missed had the MRI not been performed. ResultsThe CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination. ConclusionIn the absence of focal signs of neurologic injury, the cervical spine can be cleared without a clinical exam or MRI if the cervical CT scan does not demonstrate injury or abnormality.

Diagnosis and Treatment of Cerebral Venous Thrombosis: A Review.

Cerebral venous thrombosis (CVT), also called cerebral venous sinus thrombosis (CVST), is a cerebrovascular disease with diverse clinical manifestations that often affects young adults, women of childbearing age, and children. It's most common clinical manifestations are headache, seizures, altered consciousness, and neurological focal signs on physical examination. CVT can manifest as a single symptom, or it can present as a syndrome consisting of multiple symptoms. This non-specific clinical picture makes diagnosing CVT difficult. Although the mortality rate of CVT has been significantly reduced by improvements in treatment and diagnostic techniques, the mortality rate of severe CVT remains as high as 34.2%. Survivors of this type of CVT have varying degrees of residual symptoms and are not able to return to their previous work. Hence, we performed a comprehensive literature search in the PubMed, EMBASE, and Medline databases to review the diagnosis and treatment of CVT.

Hearing impairment after acute bacterial meningitis in children.

Objective:To determine the incidence of hearing loss after acute episode of meningitis in childrenMethods:A descriptive study carried out in the Department of Pediatric Medicine of The Children’s Hospital Lahore, Pakistan from January 2014 to July 2016. A total of 175 children one month to 13 years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry and culture sensitivity were sent. CT scan brain was done if required. Hearing assessment was done two weeks after admission using otoacoustic emissions in the patients having normal tympanogram. Hearing impairment was classified as sensorineural if otoacoustic emissions were absent while tympanometry was normal.Results:Of 175 children, 58% were males and 42% were females. Mean age was 2.1 years. Orientation as assessed by Glasgow comma scale (GCS) was normal in 63% while 5% had GCS<8 and 32% had GCS between 8 and 15. Signs of meningeal irritation were seen in 58% while focal signs only in 4%. In 15 % cases CT scan was done, out of which 73% showed abnormal findings. Otoacoustic emissions were absent in 22% of cases. Risk factors of hearing deficit were stay duration of more than 10 days (p=0.04), low GCS at presentation (p=0.009) and meningitis with complications (p=0.008).Conclusion:The frequency of hearing loss is 22% following acute episode of meningitis which necessitates the need for implementation of screening assessment after meningitis in Pakistan. Prolonged stay, low GCS and complicated meningitis are risk factors for hearing impairment.

A study on role of chest X-rays in children above 5 years admitted with asthma exacerbation

Context: Asthma is a heterogeneous disease characterized by chronic airway inflammation that causes airway hyperresponsiveness. The diagnosis of asthma is mainly clinical, and chest X-rays are not required for the diagnosis or grading of severity of disease. Aim: The aim of this study is to look at the frequency of abnormalities and the pattern of abnormalities in chest X-rays done in children above 5 years admitted with acute asthma and to analyze if chest X-ray reports altered the ongoing treatment plan. Settings and Design: It was a retrospective study done in a tertiary care hospital. Methods: Data were collected from case records of children above 5 years admitted with acute asthma between November 2014 and October 2017. Statistical Analysis: The statistical analysis was done using Chi-square and Fisher's exact test. Results: A total of 114 children were included in the study, and 84 (74%) had chest X-rays performed of which 88% were normal. Nineteen (22.6%) complied with standard guidelines, and the reason for performing chest X-rays in these children was the presence of focal clinical chest signs. When there were focal clinical findings, the possibility that chest X-ray would be abnormal was 47.37%. When there were no focal clinical findings, the possibility that chest X-ray would be normal was 98.46%. The sensitivity of chest X-rays with clinical correlation was 90% and specificity was 86.48%. Hence, routine chest X-rays in the standard treatment of acute asthma are not necessary, especially when there are no focal clinical findings. Conclusion: Chest X-ray is not required in the management of acute asthma in children above 5 years responding to standard treatment. Chest X-rays should be ordered in the management of acute asthma only when indicated, thereby reducing unnecessary exposure to radiation.