Medical Specialties Commons^™

Typical Graves' Ophthalmopathy In Primary Hypothyroidism, Zareen Kiran, Owais Rashid, Najmul Islam

Section of Diabetes, Endocrinology and Metabolism

Graves ophthalmopathy (GO) usually occurs in a close temporal relationship with hyperthyroidism. It is rare in patients with normal thyroid function (euthyroid GO) and in patients with hypothyroid forms of thyroid autoimmune diseases (hypothyroid GO). We report a 52-years old man presenting in our endocrine clinic with diagnosed primary hypothyroidism 3 months back during evaluation for glaucoma. He was later referred by an ophthalmologist to exclude Grave's eye disease, where he had presented with chief complaints of bilateral prominent eyes. On examination there was only bilateral exophthalmos with marked chemosis. Magnetic resonance imaging (MRI) of the orbits showed typical findings …

Determinants Of Knowledge Of Critical Danger Signs, Safe Childbirth And Immediate Newborn Care Practices Among Auxiliary Midwives: A Cross Sectional Survey In Myanmar, Kyu Kyu Than, Alison Morgan, Minh Duc Pham, James G. Beeson, Stanley Luchters

Population Health, East Africa

Objectives The re-emergence of community-based health workers such as the auxiliary midwives (AMWs) in Myanmar, who are local female volunteers, has been an important strategy to address global health workforce shortages. The Myanmar government recommends one AMW for every village. The aim of this study is to investigate the current knowledge of critical danger signs and practices for safe childbirth and immediate newborn care of AMWs to inform potential task shifting of additional healthcare responsibilities.

Methods A cross-sectional survey was conducted from July 2015 to June 2016 in three hard-to-reach areas in Myanmar. Face-to-face interviews were conducted using a pretested …

Metabolic Syndrome And Its Predictors In An Urban Population In Kenya: A Cross Sectional Study, Geoffrey Omuse, Daniel Maina, Mariza Hoffman, Jane Mwangi, Caroline Wambua, Elizabeth Kagotho, Angela Amayo, Peter Ojwang, Zul Premji, Kiyoshi Ichihara, Rajiv Erasmus

Pathology, East Africa

Background: The metabolic syndrome (MetS) is a clustering of interrelated risk factors which doubles the risk of cardio-vascular disease (CVD) in 5–10 years and increases the risk of type 2 diabetes 5 fold. The identification of modifiable CVD risk factors and predictors of MetS in an otherwise healthy population is necessary in order to identify individuals who may benefit from early interventions. We sought to determine the prevalence of MetS as defined by the harmonized criteria and its predictors in subjectively healthy black Africans from various urban centres in Kenya.

Method: We used data collected from healthy black Africans in …

Anthropometric Indices For Non-Pregnant Women Of Childbearing Age Differ Widely Among Four Low-Middle Income Populations, K Michael Hambidge, Nancy F. Krebs, Ana Garcés, Jamie E. Westcott, Lester Figueroa, Shivaprasad S. Goudar, Sangappa Dhaded, Omrana Pasha, Sumera Aziz Ali, Antoinette Tshefu

Community Health Sciences

Background: Maternal stature and body mass indices (BMI) of non-pregnant women (NPW) of child bearing age are relevant to maternal and offspring health. The objective was to compare anthropometric indices of NPW in four rural communities in low- to low-middle income countries (LMIC).
Methods: Anthropometry and maternal characteristics/household wealth questionnaires were obtained for NPW enrolled in the Women First Preconception Maternal Nutrition Trial. Body mass index (BMI, kg/m²) was calculated. Z-scores were determined using WHO reference data.
Results: A total of 7268 NPW participated in Equateur, DRC (n = 1741); Chimaltenango, Guatemala (n = 1695); North …

Putative Adult Neurogenesis In Two Domestic Pigeon Breeds (Columba Livia Domestica): Racing Homer Versus Utility Carneau Pigeons, Pedzisai Mazengenya, Adhil Bhagwandin, Pilani Nkomozepi, Paul R. Manger, Amadi O. Ihunwo

Brain and Mind Institute

Generation of neurons in the brains of adult birds has been studied extensively in the telencephalon of song birds and few studies are reported on the distribution of PCNA and DCX in the telencephalon of adult non-song learning birds. We report here on adult neurogenesis throughout the brains of two breeds of adult domestic pigeons (Columba livia domestica), the racing homer and utility carneau using endogenous immunohistochemical markers proliferating cell nuclear antigen (PCNA) for proliferating cells and doublecortin (DCX) for immature and migrating neurons. The distribution of PCNA and DCX immunoreactivity was very similar in both pigeon breeds with only …

Mortality In Patients With Respiratory And Nonrespiratory Carbapenem Resistant-Multidrug Resistant Acinetobacter Infections, Nosheen Nasir, S Mahmood

Department of Medicine

Background: Mortality from carbapenem-multi-drug resistant Acinetobacter infections may vary according to site of infection. The objective of this study was to compare mortality in respiratory vs. non-respiratory infection with Carbapenem-Multi-drug Resistant Acinetobacter (C-MRAB).

Methods: We conducted a prospective cohort study to compare mortality rate in patients with respiratory vs. nonrespiratory infection (n=30 each).

Results: Results showed that mortality was 40% in the respiratory group compared to 23% in non-respiratory group; the difference was not statistically significant (p=0.165, RR=1.71, CI=0.73-3.75). There was a significantly higher prior admission rate in patients with respiratory infection (p=0.028). Logistic regression did not reveal any modifier …

Incidence And Pattern Of Thrombocytopenia In Cardiac Surgery Patients, Mohammad Hamid, Mohammad Irfan Akhtar, Hamid Iqil Naqvi, Khalid Ahsan

Department of Anaesthesia

Objective: To observe the incidence and pattern of thrombocytopenia in cardiac surgery patients.
Methods: This prospective, cohort study was conducted at the Aga Khan University Hospital, Karachi, from November 2014 to April 2015, and comprised adult cardiac patients. Patients with platelet count less than 150,000 x 109/L, history of malignancy, immune thrombocytopenic purpura and on chemo or radiotherapy were excluded. All information including demographics, platelet count, heparin doses, total cardiopulmonary bypass time, cross-clamp time, blood products transfused, any thromboembolic complication and the presence of infection were recorded on a pre-designed proforma. SPSS 19 was used for data analysis..
Results: Of …

Rsv Associated Hospitalizations In Children In Karachi, Pakistan: Implications For Vaccine Prevention Strategies, Syed Asad Ali, Mohammad Tahir Yousafzai, Rabbia Waris, Fatima Jafri, Fatima Aziz, Imran Naeem Abbasi, Anita K. M. Zaidi

Department of Paediatrics and Child Health

Major progress is being made in vaccines against Respiratory Syncytial Virus (RSV), with multiple vaccine candidates currently in the clinical phase of development. Making an investment case for public sector financing of RSV vaccine will require estimation of burden, cost-effectiveness, and impact. The aim of this study is to determine the proportion, age distribution and clinical spectrum of RSV associated hospitalizations in children in Karachi, Pakistan. A three years prospective study was conducted at the Aga Khan University Hospital in Karachi, a city of 20 million in south Pakistan, from August 2009 to June 2012. Children less than five years …

Experience With The Quantitative Lyta Gene Real-Time Polymerase Chain Reaction For The Detection Of Streptococcus Pneumoniae From Pediatric Whole Blood In Pakistan, Furqan Kabir, Sahrish Muneer, Adil Kalam, Ana Sami, Shahida Qureshi, Aneeta Hotwani, Atif Riaz, Syed Mohiuddin, Mohammad Tahir Yousafzai, Sara Hussain, Syed Asad Ali, Sadia Shakoor

Department of Paediatrics and Child Health

Background: We present our experience with optimization and diagnostic use of quantitative real-time polymerase chain reaction (PCR) targeting the lytA gene of Streptococcus pneumoniae for the detection of S. pneumoniae in whole blood of children ≥5 CFU/10 μl or 1 copy of DNA/2 μl of blood.
Methods: This assay was applied on 1912 whole blood specimens collected from children pneumonia, of which 35 specimens were lytA positive. The bacterial loads were determined through categorization of load into five different categories, i.e., very high load, high load, moderate load, low load, and very low load.
Results: Of the 35 lytA-positive …

Mammographic Density And Ageing: A Collaborative Pooled Analysis Of Cross-Sectional Data From 22 Countries Worldwide, Anya Burton, Gertraud Maskarinec, Beatriz Perez-Gomez, Celine Vachon, Hui Miao, Martín Lajous, Ruy López-Ridaura, Megan Rice, Ana Pereira, Maria Luisa Garmendia, Rulla M. Tamimi, Kimberly Bertrand, Ava Kwong, Giske Ursin, Sudhir Vinayak, Rose Ndumia, Shivaani Mariapun

Imaging & Diagnostic Radiology, East Africa

Background:Mammographic density (MD) is one of the strongest breast cancer risk factors. Its age-related characteristics have been studied in women in western countries, but whether these associations apply to women worldwide is not known.

Methods and findings: We examined cross-sectional differences in MD by age and menopausal status in over 11,000 breast-cancer-free women aged 35–85 years, from 40 ethnicity- and location-specific population groups across 22 countries in the International Consortium on Mammographic Density (ICMD). MD was read centrally using a quantitative method (Cumulus) and its square-root metrics were analysed using meta-analysis of group-level estimates and linear regression models of …

Outcomes Of Post-Neurosurgical Ventriculostomy-Associated Infections, Muhammad Ehsan Bari, Ghani Haider, Komail Malik, Muhammad Waqas, Syed Faisal Mahmood, Mubbashira Siddiqui

Section of Neurosurgery

Background: Ventriculostomy-associated infection (VAI) is a major concern to physicians. Limited studies have looked at the outcomes of external ventricular drain (EVD) infection and predictors of unfavorable outcomes. In this study, we assessed the outcomes of EVD infection and predictors of unfavorable outcomes.
Methods: This was a retrospective medical chart review, conducted at the Aga Khan University Hospital. All the patients irrespective of age and gender, fulfilling the diagnostic criteria of VAI were included. Patients with preexisting bacterial meningitis or ventriculitis were excluded from the study. Outcome assessment was based on Glasgow outcome scale (GOS) at 1 and 3 months …

Patients’ Level Of Knowledge And Perception Of The Involvement Of Post-Graduate Trainees In Their Surgical Care At Aga Khan University Hospital, Nairobi., Jane Mugure Githae

Master of Medicine in General Surgery

Introduction: Surgical training is fashioned on a system of graduated responsibilities and independence for acquisition of skills and competence. While many benefit from acquisition of these skills, few would want to be the ‘practicing ground’ for the trainee surgeon. Moreover, disclosure is inappropriate and surgical care does not specifically spell out the role of the surgical trainee in these procedures. A pilot survey conducted on 20 first-time patients presenting to General Surgery and Orthopaedic Clinics at Aga Khan University Hospital, Nairobi, revealed varied understandings as to who is a post-graduate surgical trainee. Objective: To explore the patients’ level of knowledge …

Case-Control Vaccine Effectiveness Studies: Data Collection, Analysis And Reporting Results, Jennifer R. Verani, Abdullah H. Baqui, Claire V. Broome, Thomas Cherian, Cheryl Cohen, Jennifer L. Farrar, Daniel R. Feikin, Michelle J. Groome, Rana A. Hajjeh, Anita K. M. Zaidi

Department of Paediatrics and Child Health

The case-control methodology is frequently used to evaluate vaccine effectiveness post-licensure. The results of such studies provide important insight into the level of protection afforded by vaccines in a 'real world' context, and are commonly used to guide vaccine policy decisions. However, the potential for bias and confounding are important limitations to this method, and the results of a poorly conducted or incorrectly interpreted case-control study can mislead policies. In 2012, a group of experts met to review recent experience with case-control studies evaluating vaccine effectiveness; we summarize the recommendations of that group regarding best practices for data collection, analysis, …

Correlation Between Ovarian Volume And Polycystic Ovarian Syndrome Using Ultrasound., Ndecho Muriuki Guandaru

Master of Medicine in Imaging and Diagnostic Radiology

Background: Polycystic ovarian syndrome (PCOS) is the most common endocrine abnormality in women of reproductive age with a prevalence of 5-10% in different populations. The prevalence of PCOM in patients with PCOS has been shown to be ≥ 90% in different populations. Diagnostic evaluation accounts for a relatively minor part of the total costs of providing care and evaluating women with PCOS. Hence more widespread and liberal screening for the disorder appears be a cost-effective strategy in susceptible patients. PCOM on ultrasound is diagnosed if one of the following is present in one or both of the ovaries; Ovarian volume …

Outcome Of Judet's Quadricepsplasty For Knee Contractures And The Effect Of Local Infiltration Of Epinephrine On Reducing Blood Loss, Akber Jalil Zuberi, Haroon Rashid, Rizwan Haroon Rashid, Moiz Ali, Pervaiz Hashmi

Section of Orthopaedic Surgery

Objective: To evaluate the effectiveness of Judet's quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure.
Methods: A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet's quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet's …

Extent Of Resection And Timing Of Surgery In Adult Low Grade Glioma, Farhan A. Mirza, Muhammad Shahzad Shamim

Section of Neurosurgery

Low grade glioma is a group of WHO grade II tumours including diffuse astrocytoma, oligodendroglioma, and oligoastrocytoma. Strong evidence exists in literature now to support early surgery and higher extent of safe resection in improving outcomes. In this review, we are highlighting some of the important studies done in the last few years specifically addressing timing of surgery and extent of resection.

Patterns, Control And Complications Of Diabetes From A Hospital Based Registry Established In A Low Income Country., J. Akhter, Asma Ahmed, Minaz Mawani, Laila Lakhani, Ayaz Kalsekar, Shehla Tabassum, Najmul Islam

Section of Diabetes, Endocrinology and Metabolism

Background: Diabetes registry enables practitioners to measure the characteristics and patterns of diabetes across their patient population. They also provide insight into practice patterns which can be very effective in improving care and preventing complications. The aim of this study was to assess the patterns, control levels and complications at the baseline of the patients attending clinic at the large tertiary care hospital in Karachi, Pakistan with the help of the registry. This can be used as a reference to monitor the control and also for a comparison between peer groups. Methods: This was a cross sectional study with the …

Neurology Training In Pakistan: Perspectives From Physicians In A Neurology Unit Working At Different Levels, Ali Zohair Nomani, Haris Majid Rajput, Misbah Ahmed

Pakistan Journal of Neurological Sciences (PJNS)

Pakistan is a developing country of South East Asia. It stands amongst the highest in the list of high disease burden countries including that for neurological diseases. The current number of trained neurologists in the country is extremely low and the facilities not too frequently available.

Case Of A Young Girl With Hemichorea Induced By Oral Contraceptive Pills, Syeda Saba Zaidi

Pakistan Journal of Neurological Sciences (PJNS)

Chorea is an involuntary movement disorder characterized by brief, abrupt, non-repetitive, non-rhythmic movements with dance-like appearance, moving from one body part to another. When chorea involves half of the body then the term hemi-chorea is used, which usually signify structural pathology in the contralateral Basal ganglia. Use of Oral contraceptive pills, is a well-established but a rare cause of hemi-chorea. Mechanism includes either re-activation of Sydenham's chorea or drug induced lupus erythematosus. Although our case does not have any systemic manifestation of lupus but ANA positivity likely favors later mechanism. We described a case of a young girl who developed …

Is Time Of Birth A Predictor Of Adverse Perinatal Outcome? A Hospital-Based Cross-Sectional Study In A Low-Resource Setting, Tanzania, Andrew H. Mgaya, Januarius Hinju, Hussein Kidanto

Faculty of Health Sciences, East Africa

Background Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes.

Methods A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed …

Stages Of Chronic Kidney Disease And Soluble Transferrin Receptor (Stfr), Ferritin, Ratio, Faiza Alam Faiza Alam, Syeda Sadia Fatima, Sabeela Noor Sabeela Noor, Ahmed Bilal, Rehana Rehman

Department of Biological & Biomedical Sciences

Objective: To assess the ratio of soluble transferrin receptor to ferritin in different stages of chronic kidney disease.
Methods: This case-control study was conducted at the Aga Khan University Hospital and the Jinnah Postgraduate Medical Centre, Karachi, from January to September 2014, and comprised chronic kidney disease patients and healthy controls. Group 1 comprised controls, whereas groups 2, 3 and 4 had patients based on their mean glomerular filtration rate. SPSS 19 was used for data analysis.
Results: Of the 170 participants, 126(74.1%) were cases and 44(25.9%) were controls. The overall mean age was 55.87±3.48 years and the mean body …

Knowledge And Trends Of Caffeine Consumption Among Medical And Non Medical Students Of Lahore Pakistan, Mubashir Ahmad, Rashk E Hinna, Ahmad Tayyab

Pakistan Journal of Neurological Sciences (PJNS)

To determine the rate of the caffeine consumption among students and to assess side effects and benefits of the caffeine among medical and non-medical students. METHODOLOGY: This cross-sectional study was included medical and non-medical students of various institutes of Lahore. The study duration was three months from May 2014 to July 2014. A predesigned structured questionnaire was used to collect data from the students, Consent was obtained on the form beforehand. RESULTS: Astonishingly 98.6%(74) of medical and 97.4%(73) of the Non-Medical students said that they consume caffeine in one form or another, the most popular caffeinated product turned out to …

Infections In Post Stroke Setting: A Study From The Neurology Section Of Aga Khan University Hospital, Karachi, Rizwana Shahid, Azra Zafar, Mohammad Wasay

Pakistan Journal of Neurological Sciences (PJNS)

Stroke is one of the commonest neurological disorders, contributing to the major burden of inpatient and outpatient neurology services. Infections after the stroke are the major factor, contributingto prolonged hospital stay and poor outcome in term of increasing morbidity and mortality. The aim of this study is to define the different types of infections in post stroke patients and their impact on the outcome of patients with stroke. METHOD: This is a descriptive, cross sectional study, that was carried out in the section of Neurology, Department of Medicine at Aga Khan University Hospital, Karachi over the span of one year. …

Microalbuminuria In Type-2 Diabetes Mellitus; The Tip Of Iceberg Of Diabetic Complications., Tauseef Ahmad, Imran Ulhaq, Minaz Mawani, Najmul Islam

Section of Diabetes, Endocrinology and Metabolism

Objective: To determine the prevalence of microalbuminuria and its association with hypertension and other diabetic complications among Type-2 diabetic patients attending at Aga Khan University Hospital Karachi.

Methods: 1280 Type-2 diabetes patients who visited the outpatient department of Aga Khan University Hospital from September 2014 to August 2016 were included in the study. Microalbuminuria was diagnosed if spot urinary microalbumin excretion was confirmed to be more than 20mg/l. Hypertension was diagnosed if BP >140/90 or already on antihypertensive medications. Other demographic, clinical and laboratory data were also recorded. Results: Microalbuminuria was diagnosed in 404(31.56%) patients and among these albuminuric patients …

Vitamin-D Toxicity And Other Non-Malignant Causes Of Hypercalcemia: A Retrospective Study At A Tertiary Care Hospital In Pakistan, Muhammad Naeem Khan, Qamar Masood, Mohammad Arsalan Siddiqui, Sabahat Naz, Najmul Islam

Section of Diabetes, Endocrinology and Metabolism

Background: Hypercalcemia is a common clinical problem; primary hyperparathyroidism and malignancy is commonest causes of hypercalcemia. Aetiology of hypercalcemia are changing, causes that were diseases of the past like Vitamin-D toxicity and milk alkali syndrome are observed more often. Vitamin-D deficiency is an important problem and overzealous replacement of Vitamin-D has been observed, suspected to cause toxicity.

Methods: This was a retrospective review of patients admitted at the Aga Khan University Hospital from January 2008 to December 2013 with hypercalcemia. We reviewed the electronic health records for laboratory and radiological studies, and discharge summaries to establish the cause of hypercalcemia. …

Determinants And Impact Of Giardia Infection In The First 2 Years Of Life In The Mal-Ed Birth Cohort, Elizabeth T. Rogawski, Luther A. Bartelt, James A. Platts-Mills, Jessica C. Seidman, Amidou Samie, Alexandre Havt, Sudhir Babji, Shahida Qureshi, Sadia Shakoor, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Giardia are among the most common enteropathogens detected in children in low-resource settings. We describe here the epidemiology of infection with Giardia in the first 2 years of life in the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED), a multisite birth-cohort study.
Methods: From 2089 children, 34916 stool samples collected during monthly surveillance and episodes of diarrhea were tested for Giardia using an enzyme immunoassay. We quantified the risk of Giardia detection, identified risk factors, and assessed the associations with micronutrients, markers of gut inflammation and …

Human Cytomegalovirus: A Neglected Public Health Area Of Significant Relevance To Women, The Foetus And New Born. Time For Action!, Amna Rehana Siddiqui, Saira Ibrahim, Anwar Ali Siddiqui, Paul Moss, El-Nasir Lalani

Community Health Sciences

No abstract provided.

Multicomponent Intervention Versus Usual Care For Management Of Hypertension In Rural Bangladesh, Pakistan And Sri Lanka: Study Protocol For A Cluster Randomized Controlled Trial., Tazeen H. Jafar, Imtiaz Jehan, H. Asita De Silva, Aliya Naheed, Mihir Gandhi, Pryseley Assam, Eric A. Finkelstein, Helena Legido Quigley, Marcel Bilger, Aamir Hameed, John David Clemens, Shah Ebrahim, Elizabeth L. Turner, Anuradhani Kasturiratne

Community Health Sciences

BACKGROUND:

High blood pressure (BP) is the leading attributable risk for cardiovascular disease (CVD). In rural South Asia, hypertension continues to be a significant public health issue with sub-optimal BP control rates. The goal of the trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering BP among adults with hypertension in rural communities in Bangladesh, Pakistan and Sri Lanka.

METHODS/DESIGN:

This study is a stratified, cluster randomized controlled trial with a qualitative component for evaluation of processes and stakeholder feedback. The MCI has five components: (1) home …

Hypertensive Supratentorial Intracerebral Hemorrhage: Early Surgery And Functional Outcome; A Tertiary Care Hospital Experience From Karachi, Pakistan., Muhammad Imran, Atiq Ahmed Khan, Syed Ijlal Ahmed, Shiraz Ahmed Ghouri, Muhammad Osama Farooqi, Alizay Rashid Khan, Majid Chandio

Pakistan Journal of Neurological Sciences (PJNS)

BACKGROUND: Spontaneous supratentorialintracerebral hemorrhage (ICH) has a high morbidity and mortality and places a significant burden on health and social services.The role and timing of operative neurosurgical intervention remain controversial and the practice and timing of surgery continue to be haphazard. METHODOLOGY: Our study was a descriptive study conducted at Civil hospital Karachi, Pakistan. Sample size was calculated. The sampling technique of our study was non probability. The data was collected and analyzed using spssvs 17. Data was observed for any descriptive and inferential statistics. RESULTS: There were 38 males (63.3%) and 22 females (36.7%). The mean age of patients …

Respiratory Distress In Patients Of Guillain-Barre Syndrome With Sensory Manifestations, Maher Bano Malik, Haris Majid Rajput, Jahangir Shoro

Pakistan Journal of Neurological Sciences (PJNS)

Guillain-Barré syndrome (GBS) is one of the most frequent disorder of peripheral nervous system associated with respiratory distress. One clinical parameter that was found significant in heralding the onset of respiratory failure in GBS weresensory manifestations. The aim of the study was to determine the frequency of respiratory distress in patients of GuillainBarresyndrome with or without sensory manifestations in the disease. MATERIALS AND METHODS: This was a descriptive case seriesthat was conducted from January 19, 2013 to July 18, 2013 in Department of Neurology, Pakistan Institute of Medical Sciences, Islamabad. All patients who met the inclusion criteria were selected for …