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Spectral domain optical coherence tomography (SD-OCT) was used to assess the perifoveal Ganglion cell complex (GCC) thickness in healthy Pakistani children. 174 eyes of 87 healthy children (3 to 16 years) were included after a thorough eye examination. Significant refractive error was excluded (± 5 DS), glaucoma, ocular pathology, intraocular surgery, trauma, and systemic ailments. The perifoveal GCC analysis was done by Optopol Revo 80® high resolution SD-OCT. The average age was 11.1 ± 3.12 years. The average GCC thickness globally was 120.01 ± 76.74 μm, superiorly; 117.51 ± 8.77 μm, superonasally; 120.47 ± 8.78 μm, superotemporally, 103.83 ± 8.25 μm, inferiorly; 117.41 ± 8.71 μm, inferonasally 120.57 ± 8.88 μm, and inferotemporally; 107.15 ± 7.69 μm. The average GCC thickness was positively correlated with axial length (p = .02) and the GCC thickness in all sectors was significantly higher amongst males as compared to females (p .05). Our study provides normative data for the macular GCC thickness in healthy children of our population. GCC thickness estimation is an important diagnostic parameter in glaucoma and optic neuropathies. Establishing a normative database for our pediatric population would help immensely in the diagnosis and monitoring of optic nerve disorders. RESEARCH HIGHLIGHTS: Spectral domain optical coherence tomography guided measurement of the ganglion cell complex thickness of the Pakistani pediatric population has not been done before. Our study provides normative data for the macular ganglion cell complex in healthy children of our population and studies its correlations with age, gender, intraocular pressure, axial length, refractive status, and corneal thickness. This will guide us in optic nerve and neurological disease diagnosis and monitoring.

Strabismus, whether congenital or acquired, is a common visual and cosmetic problem, especially for the young. Adjustable suture strabismus surgery is not in vogue in our country. This technique gives the surgeon a second attempt to provide a better outcome for the patients. Our objective was to assess the long-term success of adjustable strabismus surgery in terms of postoperative alignment.We carried out a prospective study utilizing the fornix approach for adjustable strabismus surgery, in mainly horizontal, but also vertical strabismus in adults and cooperative children, to enhance the postoperative outcomes. The patient characteristics, preoperative deviation, type and pattern of strabismus, were evaluated and analyzed. The postoperative alignment was evaluated at 1 year and beyond, to assess the success of this adjustable surgery.This study recruited 50 adults and children with a female predominance of 39 (78%); and with the mean age being 18.34 ± 9.88 years. Exotropia was the primary diagnosis in the majority with 21 (42%) cases; with purely horizontal strabismus in 23 (46%) cases. The mean preoperative horizontal deviation was 48.76 ± 20.35 prism diopters (PD) and the mean postoperative horizontal deviation was 2.73 ± 3.63 PD. The mean preoperative vertical deviation was 4.8 ± 8.54 PD whereas the mean postoperative vertical deviation was 0.86 ± 1.73 PD. The Wilcoxon Signed Ranks test analyzed the difference between the two which was statistically significant (p = 0.000). Surgical success, defined as postoperative horizontal alignment within ≤ 10 PD of orthotropia at the end of one year or more of follow-up after surgery, was achieved in 49 (98%) cases. The average follow-up was 21.47 ± 8.7 months.Adjustable strabismus surgery has very good long-term outcomes in terms of postoperative alignment and patient satisfaction.

Purpose To report the occurrence and the outcomes of 2 cases of spontaneous extrusion of 3-piece intraocular lens (IOL) through a Gundersen conjunctival flap performed for tectonic purposes after multiple failed penetrating keratoplasties (PKs). Methods A 70-year-old woman (Patient #1) with severe dry eye disease who had undergone cataract surgery with posterior chamber 3-piece IOL implantation, multiple PKs and Gundersen conjunctival flap in her left eye presented with partial extrusion of the optic and the inferior haptic of the IOL through the conjunctival flap. Inferior symblepharon and keratinization of the entire ocular surface were also present. A 64-year-old diabetic man (Patient #2) with history of cataract surgery with a posterior chamber IOL implantation, multiple PKs for keratoconus and Gunderson conjunctival flap in his right eye presented with partial extrusion of IOL optic through the conjunctival flap. Results Patient #1 refused a further surgery and IOL was removed at the slit lamp. Currently, 3 months after IOL extrusion, corneal perforation self-sealed, visual acuity of light perception is maintained, and the patient does not complain any symptoms of ocular discomfort or pain. In Patient #2, tectonic PK combined with IOL removal and anterior vitrectomy was performed. Currently, 1 month postoperatively corneal graft is clear, intraocular pressure is normal, and patient's vision is counting fingers. Conclusions In both cases, IOL extrusion occurred spontaneously through a Gunderson conjunctival flap. Including the underlying Tenon's capsule in the conjunctival graft could increase its tectonic support, potentially avoiding this complication.

This is a peculiar case of localized, silvery, iridescent crystal deposition in the cornea and lens, discovered twenty seven years after injury with an overhanging tree branch with sap exposure. The corneal tear at the time of injury was self sealing and there was also associated lens trauma, both managed conservatively on an inpatient basis, and leading subsequently to a corneal scar and localized cortical cataract, respectively, both demonstrating fine, silver, interspersed crystals. This is the first case to be reported in the world, of corneal crystal deposition in conjunction with lenticular crystals as a result of a tree branch injury.

PurposeTo assess the anterior segment parameters in healthy children, using high resolution spectral domain optical coherence tomography (SD-OCT).DesignProspective, observational studyMethods108 eyes of 54 healthy children ≤16 years were included after a thorough eye examination. Significant refractive error (>±5 DS), history of previous glaucoma, ocular pathology, intraocular surgery, trauma or systemic ailments were excluded. The anterior segment analysis was done by Optopol Revo 80® high resolution SD-OCT. Central corneal thickness (CCT), Angle opening distance (AOD), Anterior chamber (AC) angle, Trabecular iris space area (TISA), Trabecular iris angle (TIA), iris thickness at 2 mm, internal AC diameter and lens vault were evaluated.ResultsMean age was 11.38±3.18 years with a female predominance; 29 (53.7%). Mean IOP was 13.63±2.90 mmHg, mean axial length was 22.82±0.89 mm, mean spherical equivalent was -0.14±1.28 D, mean CCT was 532.6±46.09mm and mean CDR was 0.31±0.19. The mean internal AC diameter was 11609.15±2354 µm. The nasal AC angle was 53.54±11.82° and significantly wider than the temporal AC angle; 50.37±10.26° [p=0.008]. The nasal AOD500 was 0.9±0.33 mm and not significantly greater than the temporal AOD500, 0.85±0.28 mm [p=0.09]. The nasal AOD750 was 1.21±0.45 mm, significantly greater than the temporal AOD750, 1.06±0.32 mm [p=0.001]. The nasal TIA was 41.75°; not significantly greater than the temporal TIA, 40.24° [p=0.246]. The nasal TISA500 was 0.33±0.15 mm2; not significantly wider than the temporal TISA500, 0.31±0.10 mm2 [p=0.056]. The nasal TISA750 was 0. 59±0.22 mm2; not significantly wider than the temporal TISA750, 0.56±0.21 mm2 [p=0.14]. The nasal iris thickness at 2 mm from pupil was 483.54±129.56 µm; not significantly different from the temporal iris thickness, 505.8±138.85 µm [p=0.08]. The mean lens vault was - 519.58±359µm.ConclusionsOur study data depicts the normal anterior segment parameters in healthy children. This will be useful in diagnosing and managing ocular pediatric pathology.Key MessagesAnterior segment OCT is still an emerging technique especially in pediatric eye assessmentAnterior segment evaluation via OCT has not been reported in our pediatric populationOur study describes a detailed assessment of anterior segment in pediatric eyesReporting results of normative data helps in diagnosing ocular pathology

BackgroundTo assess the pediatric anterior segment characteristics in ocular pathology, using spectral domain optical coherence tomography (SD-OCT).MethodsOur case series follows 115 eyes of 78 children aged 2–17 years of age with anterior segment pathology in an academic facility. A thorough eye examination and investigations were performed for each child. The anterior segment optical coherence tomography (AS-OCT) analysis was done using the Optopol Revo 80®high resolution SD-OCT (840 nm, axial resolution of 5 µm) using an imaging adapter. All pathological features visible on imaging were observed, studied, tabulated, and analyzed.Results115 eyes of 78 children with anterior segment pathology were imaged. The average age was 11.84 years, with 44 males and 34 females. The primary clinical diagnosis wascataract(congenital and acquired) in 40 (34.8%) eyes, followed bycorneal disease(congenital, inflammatory, and traumatic) in 28 (24.3%) eyes,glaucoma(juvenile and secondary) in 18 (15.7%) andtraumain 15 (13%) eyes. Systemic diseases were associated in 20.9%. The commonest imaging pathology observed waslens opacification(any morphology/location) in 43 (37.4%),increased reflectivity of the corneain 31 (28.2%), corneal stromal thinningin 34 (29.6%), increased corneal thickness in 28 (24.3%),shallow anterior chamberin 17 (14.8%), andcells in anterior chamberin18 (15.7%) eyes, along with a multitude of other findings.ConclusionsOur study demonstrates that anterior segment optical coherence tomography is a useful non-contact technique used without sedation for the detailed anatomic and pathologic assessment, imaging, diagnosis, and monitoring of pediatric ocular diseases.

Isolated sphenoid sinus mucocoeles are rare; whereas, benign lesions usually discovered incidentally. These may present with headache, diplopia, visual loss or ocular motor nerve palsies, due to slow expansion and mass effects. Prompt endoscopic removal is the key to prevent permanent sequelae. We present the case of a 63-year femele, who presented with sudden loss of vision of the left eye, along with periorbital and retrobulbar pain for the last one month. She was found to have "no light perception" vision in the left eye and optic atrophy. Neuroimaging was performed, which revealed a sphenoid sinus mucocoele, impinging on the left optic nerve. Our ENT Department performed endoscopic sinus surgery and removed it, but her vision did not return at 6-month follow-up. Although very rare, sphenoid sinus mucocoeles should be considered in the differential diagnosis of any patient, who presents with sudden visual loss. Key Words: Sphenoid sinus, Mucocoele, Optic neuropathy, Visual loss.

The authors have requested that this preprint be removed from Research Square.

We present a case of bilateral isolated superior rectus paresis in a 13-year girl who presented with alternating exotropia and hypertropia. She demonstrated bilateral paresis of elevation in abduction with an overaction of both the contralateral yoke muscles, i.e. inferior obliques. Neuroimaging did not reveal a lesion along the pathway of the third nerve nor hypoplasia of the superior rectus muscle. We performed a bilateral lateral rectus recession on adjustable sutures with bilateral myectomy of the inferior obliques (weakening of contralateral yoke muscle). At 1 year, the patient is well aligned and happy. Isolated extraocular muscle pareses are rare events, which present occasionally to the strabismus surgeons and need to be looked out for if the patient's strabismus looks peculiar. We believe we are the first to report an isolated paresis of the superior rectus muscle in Pakistan.

Purpose: To compare the results of trabeculectomy with subconjunctival Bevacizumab and 5-Fluorouracil (5-FU); with trabeculectomy with 5-FU alone; in terms of intraocular pressure (IOP) lowering, bleb formation, and complications, in the long term. Study Design: Quasi experimental study. Place and Duration of Study: Fauji Foundation Hospital, Rawalpindi, from December 2013 to August, 2019. Methods: A total of 30 eyes (15 in each group) with glaucoma were recruited. Exclusion criteria were previous trabeculectomy, congenital, traumatic, uveitic, neovascular glaucomas, aphakia, or ocular surface disease. Trabeculectomy with 5FU was performed in both groups. In one group, subconjunctival Bevacizumab was injected into the bleb at the end of surgery. The patients were observed for IOP control, bleb configuration, and complications for 1 year. Results: Primary open angle glaucoma was the predominant diagnosis in 17 (56.7%) eyes. The mean pre-operative IOP in the 5-FU group was 30.8 ± 17.03 mmHg, & in the 5-FU+Bevacizumab group it was 28.9 ± 18.9 mmHg. The mean IOPs of the 5-FU group at 1 Year was 14.5 ± 5.04 mmHg. In 5-FU+Bevacizumab group, mean IOPs at 1 year was 12.7 ± 4.38 mmHg. The differences between pre-operative and post-operative IOPs in both groups at 6, 9 and 12 months were statistically significant. However, differences in mean IOPs between the two groups, bleb morphology and complications were not statistically significant. Conclusion: No added benefit of subconjunctival Bevacizumab used as an adjunct to 5-FU enhanced trabeculectomy was found at the end of 1 year follow-up. Key Words: Trabeculectomy, 5-Fluorouracil, Bevacizumab, Glaucoma, Intraocular pressure.

A 76-year-old, hypertensive lady, presented with a three year history of gradual decrease in vision in her right eye. Examination revealed a large, bullous, serous pigment epithelial detachment (PED) of right fovea, a choroidal neovascular membrane, clusters of hard exudates, drusen and surrounding, multifocal, small PEDs. The left eye showed a series of small PEDs mostly on the inferior macula, pigmentary disturbance of the retinal pigment epithelium and scant hard exudates. A diagnosis of Polypoidal choroidal vasculopathy was made. We decided to treat her with intravitreal Bevacizumab injections in her right eye. At 18 months of follow up, her PEDs had resolved and visual acuity had improved from 6/60 OD to 6/36. Key Words: Polypoidal Choroidal Vasculopathy, Age Related Macular Degeneration, Pigment Epithelial Detachment, Choroidal Neovascular Membrane.

Purpose: To study the different types of pattern strabismus and their surgical outcomes after adjustable strabismus surgery. Study Design: Prospective, interventional study. Place and Duration of Study: Eye department, Fauji Foundation Hospital, Rawalpindi (June, 2016 to March, 2019). Methods: A total of 40 consecutive patients with pattern strabismus were included in the study. After complete orthoptic assessment, the patients underwent either rectus muscle transposition or oblique muscle surgery, by adjustable squint surgery. The pre-operative evaluation of different strabismus patterns, deviations, and post-operative results were measured and analyzed. The amount of postoperative pattern change was measured at 6 weeks postoperatively, to assess the success of the surgeries. Results: Out of 40 patients, 33 were females and 7 were males. The age ranged from 7 to 69 years (mean 18.05 ± 9.6). All patients were operated by using adjustable suture technique. “V” pattern was seen in 26 cases (65%) and “A” pattern was seen in 12 (30%) cases. The mean preoperative pattern was 13.2 ± 8.09 PD (prism diopters), and the mean postoperative pattern was 2.05 ± 2.96 PD. Surgical success was defined as the amount of pattern collapse at 6 weeks, the period at which a stable alignment was achieved. The difference between the preoperative and postoperative pattern deviation was statistically significant (p = 0.000). Correction of the pattern was seen in 92.5% of patients at average follow up of 50.87 ± 14.02 days. Conclusions: Pattern Strabismus can be corrected by varying rectus muscle transpositions or oblique muscle surgery during routine adjustable strabismus surgery. Key Words: Strabismus, V pattern, A pattern, Y pattern, X pattern, lambda pattern, muscle transposition.

Scintigraphic techniques have opened a new era of developments in the localization of infectious and cancerous foci. Diseases area targeting mechanisms of radiopharmaceuticals encompasses visualization, characterization, and measurement of physiological and biological functioning at targeted sites in addition to measure the area and density of the disease. The accumulation of a radiopharmaceutical at specific organ is based upon numerous processes such as enzymatic interactions, receptor binding site, transport of chemical species and elimination of damaged cells from circulation by a normal metabolic process. PET and SPECT are developing scanning techniques that provides effective diagnostic tool to identify pathophysiology of diseased cells. In this chapter, we are exploring and explaining different mechanisms of radiopharmaceutical localization for imaging and therapeutic processes. The knowledge of these mechanisms will help to develop target based new radiopharmaceuticals using variety of medically used radioisotopes either for imaging or therapy of diseased cells.

Arcus senilis is the commonest of the corneal degenerations and presents as a whitish or yellowish band in the corneal periphery, associated with the deposition of lipoproteins in the corneal stroma. It is separated from the limbus by a clear zone. It is most commonly associated with aging. Other associations are hyperlipidemia, particularly in men less than 50 years (arcus juvenilis). However, a double arcus is very rare and only few case reports are found in literature. I present a case of 68-year-old man with diabetes mellitus and 35 pack years of smoking who presented to us in the Out Patient Department. He had double corneal arcus in both eyes. There was a distinct clear line between the two arci. The case is presented with a brief discussion on the traditional risk factors, possible pathogenesis and literature review. Key Words: Arcus senilis, Gerontoxon, Arcus Juvenilis.

Lateral rectus palsy with hypotropia constitutes a portion of sixth nerve palsy cases in which only the superior compartment of the lateral rectus is palsied. We present such a case in a 10-year-old girl who presented with a peculiar appearing right esotropia and hypotropia due to acquired lateral rectus palsy along with apparent ipsilateral superior rectus underaction. Neuroimaging confirmed atrophy of the superior part of lateral rectus as compared to the inferior half. Augmented superior rectus transposition to the lateral rectus along with adjustable bimedial recessions and bilateral inferior oblique myectomies were done to restore her cosmetic appearance.

Purpose: To assess the pain experienced by patients at the time of suture adjustment using topical proparacaine hydrochloride 0.5% anesthesia, in adjustable suture strabismus surgery. Study Design: Prospective, interventional study. Place and Duration of Study: Eye department of Fauji Foundation Hospital, Rawalpindi from May, 2017 to March, 2019. Material and Methods: A prospective study was carried out to assess the pain experience of patients undergoing suture adjustment under topical proparacaine hydrochloride 0.5% anesthesia, during routine adjustable squint surgery. All surgeries were performed under general anesthesia with suture adjustment done 1 hour or more after surgery when the effects of general anesthesia had worn off. Horizontal and vertical muscle recessions and resections were included along with inferior oblique surgeries, and transposition procedures. The patients were given the ‘Wong-Baker FACES® Pain rating Scale’; along with a ‘Numeric Pain Rating Scale’ from 0 to 10 (0 signifying ‘no pain’ and 10 signifying ‘worst possible pain’) on a proforma. The response of the patients was noted. Results: Thirty three patients who underwent adjustable strabismus surgery were included in this study. The mean age was 19.1 ± 11.1 years. The average number of muscles operated upon for each patient were 2.87 ± 1.08. The patients’ response to the ‘Wong-Baker FACES® Pain rating Scale’ ranged from 0 to 8, with a mean of 2.03 ± 1.81 SD. On the ‘Numeric Pain Rating Scale’ a similar response was obtained with a mean of 2.0 ± 1.82 SD. Augmentation of anesthesia was not needed in any patient. Conclusion: Adjustment of sutures under topical proparacaine hydrochloride 0.5% anesthesia after strabismus surgery is a practical, comfortable and safe procedure.

We present a very strange case of a 44-year-old diabetic lady who presented with what appeared to be a cataractous lens dislocated in the anterior chamber of her left eye, following weight bearing, a week prior to presentation. The possibility of this being the lens became doubtful on slit lamp examination, as keratic precipitates and flare was noted bilaterally. Her pupil was miosed rendering posterior segment view extremely difficult. Subconjunctival mydriacaine and dexamethasone were given along with topical steroids and cycloplegics, which allowed a better view of the pupillary area, revealing a hint of a nuclear sclerotic cataract, very well in its natural anatomical location. This is a rare presentation of exudate in anterior uveitis presenting as a lens-like mass, producing such an illusion, as to completely baffle doctors regarding its diagnosis. The mass-like exudate subsequently diminished with topical therapy, and disappeared in around a week’s time. Both eyes are quiet at a five months follow-up.

Background This study aimed to compare the epidemiology, clinical presentations, management, and outcomes of renal colic presentations in two major academic centers from geographically diverse populations: Qatar (a country in the Afro-Asian stone belt) and South-Eastern Australia (not within a stone belt). Methods We undertook a retrospective cohort study of patients with renal colic who presented to the Hamad General Hospital Emergency Department (HGH-ED), Qatar, and The Alfred ED, Melbourne, Australia, during a period of 1 year from August 1, 2012, to July 31, 2013. Cases were identified using ICD-9-CM codes, and an electronic template was used to record the data on predefined clinical variables. Results A total of 12,223 from the HGH-ED and 384 from The Alfred ED were identified as renal colic presentations during the study period. The rate of renal colic presentations at the HGH-ED was 27.9 per 1000 ED visits compared to 6.7 per 1000 ED visits at The Alfred ED. Patients presenting to the HGH-ED were significantly younger [34.9 years (29.0–43.4) than The Alfred ED [48 years (37–60); P

Background: The outcomes of treatment and treatment cost are very much helpful to ascertain the disease and treatment effects. Objective: This research aims to assess the QoL (Quality of Life) and treatment cost on the patients of PD (Parkinson’s Disease). Furthermore, it also aims to analyze the correlation of disease treatment, cost and quality of life. Methods: This cross-sectional research was conducted at Jinnah Hospital, Lahore from March 2017 to April 2018 with the help of a survey that included a questionnaire to take the response of the participants. We documented PD associated resource consumption, clinical features and loss of productivity in the past twelve months timeframe. Statistical scales were also utilized in this research for the calculation of cost and communal perspective. Results: Among a total of 110 patients there were 38 females (34.5% female) and 70 males (63.5%); moreover, the information about gender for two patients was missing. Mean age and disease duration were respectively (63.3 ± 11.3) years and (8.2 ± 5.8) years. PDQ-39 summary and EQ-5D score were respectively (48.1 ± 13.4) and (0.59 ± 0.28) which was lower than the age bracket from 45 years to 74 years. There was a significant association between EQ-5D & PDQ-39 (P-Values 20.47 & 0.000). In terms of cost the direct medical cost, direct non-medical cost and indirect cost was respectively 35.7%, 29.4% and 34.9%. There was an increase in the disease duration of one year and a decrease in the utility of EQ-5D of 0.1 which increased the yearly cost from 8% to 10% and 7.8% respectively. PDQ-39 score non-significantly effects the total cost. Conclusions: General public health and severity of the Parkinson Disease highly affect the magnitude of quality of life loss. PD associated cost is enormous which are affected by EQ-5D, disease duration and cost. Keywords: Disease, Parkinson’s Disease (PD), Quality of Life (QoL), Medical, Cost and Disease Duration.

Objectives: The objective of this study was to compare the effectiveness of clomiphene citrate and letrozole among ovulatory infertile females. Material and Methods: We carried out this randomized controlled trial at Jinnah Hospital, Lahore from October 2017 to June 2018 on a total of 224 ovulatory infertile females which were in the age bracket of 18 – 40 years. Results: We selected women in the age limit of 18 – 40 years which were divided into two main groups Group – A (Clomiphene Citrate) & B (Letrozole) with a respective mean age of (26.72 ± 6.02) years and (26.87 ± 6.33) years. Most dominant age bracket was 18 – 30 years among 148 patients (66.07%). Mean infertility duration was (3.47 ± 2.21) years; for Group – A & B the mean infertility duration was (3.23 ± 2.19) years and (3.68 ± 2.34) years. Group – A efficacy was reported in 19 patients (16.96%) and for Group – B among 37 patients (33.04%) (P-Value = 0.005). Conclusion: The outcomes conclude that Clomiphene Citrate is less effective than Letrozole in order to achieve pregnancy among ovulatory infertility females. Keywords: Ovulatory, Letrozole, Infertility, Clomiphene Citrate, Efficacy and Pregnancy.

Objectives There is little information available from the Middle Eastern region on adult patients presenting with first seizure. The objectives of this study were to describe epidemiological characteristics of patients presenting to the emergency department (ED) in Doha, Qatar, with first seizure and to determine the incidence of computed tomographic (CT) scan abnormalities. Methods A retrospective cohort study was conducted on all adult patients with first seizure presenting to Hamad General Hospital ED over a 1-year period (June 2012 through May 2013). Electronic patient records were reviewed for demographics, neuroimaging, electroencephalography, laboratory test results, and medications administered. Results There were 439 patients who satisfied inclusion criteria. Patients were aged a mean of 35.3 years (95% confidence interval [CI] = 33.92 to 36.69 years) with a male-to-female ratio of five to one. CT abnormalities were detected in 154 patients (35.3%; 95% CI = 30.81% to 39.82%). Out of reported abnormal scans, 14.7% patients had significant abnormalities such as neurocysticercosis (9.2%); brain metastasis and neoplasm (3.4%); and subarachnoid and subdural hemorrhage, cavernous sinus thrombosis, acute stroke, and brain edema (2.0%). None of the patients had any electrolyte abnormalities, and three patients had hypoglycemia. Patients with initial abnormal CT brain results were more likely to have recurrent seizures (OR = 1.65; 95% CI = 1.11 to 2.45) within 6 months. Conclusions Adults who presented with first seizure to the ED in Qatar had a young male predominance, and a high proportion of brain CT scans were reported as abnormal. It is recommended that all such patients in this population should undergo prompt CT scanning in the ED, but the utility of routine electrolyte tests requires further investigation. Resumen Objetivos Existen poco datos de la region del Medio Este del mundo en pacientes atendidos con una primera crisis epileptica. Los objetivos de este estudio fueron describir las caracteristicas epidemiologicas de los pacientes atendidos en el servicio de urgencias (SU) en Doha, Qatar, con una primera crisis epileptica y determinar la incidencia de alteraciones en la tomografia computarizada (TC). Metodologia Estudio de cohorte retrospectivo que se llevo a cabo en todos los pacientes adultos atendidos por una primera crisis epileptica en el SU del Hamad General Hospital durante el periodo de un ano (junio 2012 a mayo 2013). Se revisaron las historias clinicas electronicas de los pacientes para los datos demograficos, la neuroimagen, la electroencefalografia, las pruebas de laboratorio y los farmacos administrados. Resultados Hubo 439 pacientes que cumplieron los criterios de inclusion. La edad media de los pacientes fue de 35,3 anos (IC 95% = 33,92 a 36,69 anos) con una proporcion varon/mujer de 5 a 1. Las alteraciones en la TC se detectaron en 154 pacientes (35,3%; IC 95% = 30,81% a 39,82%). Del total de los escaneres con alteraciones documentadas, un 14,7% de los pacientes tuvo una alteracion significativa como neurocisticercosis (9,2%), neoplasia o metastasis cerebral (3,4%), o hemorragia subaracnoidea y subdural, trombosis seno cavernoso, ictus agudo y edema cerebral (2,0%). Ninguno de los pacientes tuvo ninguna alteracion hidroelectrolitica y tres pacientes tuvieron hipoglucemia. Los pacientes con una TC alterada inicialmente resultaron tener mayor probabilidad de crisis epilepticas recurrentes (OR 1,65; IC 95% = 1,11 a 2,45) en los 6 primeros meses. Conclusiones Los adultos que se atendieron por una primera crisis epileptica en el SU de Qatar tuvieron una predominancia masculina y edad joven y una alta proporcion de escaneres cerebrales con anormalidades. Se recomienda que a todos los pacientes similares en esta poblacion se les lleve a cabo una TC de forma precoz en el SU, pero la utilidad de las pruebas diagnosticas de los electrolitos de forma rutinaria requiere de futuras investigaciones.

Introduction: Acute aortic dissection (AAD) is one of the most challenging cardiovascular emergencies presenting to the Emergency Department (ED). Prompt diagnosis and treatment is the key to patient survival. Though most AADs present with typical symptoms, it has been reported to present with a myriad of symptoms. We report a case of an AAD, which presented to our ED with predominant neurological symptoms. Case description: A 47-year-old male was brought to our ED with acute confusion and history of seizure. He did not have any history of trauma or report any chest pain, headache or fever. He was vitally stable except for slight tachycardia and his physical examination was unremarkable. All investigations including a CT head were reported normal except leukocytosis (27 × 109/L). A few hours after admission, he started deteriorating, developed hypotension and became more agitated. Resuscitative measures were started. Ultrasound scan of the heart was performed to confirm central venous access showed a pericardial effusion and a flap in the ascending aorta. A diagnosis of AAD was made. An urgent CT was performed, which showed an extensive Type A aortic dissection extending into the branches, with rupture into pericardial cavity. During transportation for surgery, the patient had a cardiac arrest from which he could not be resuscitated. Conclusion: AADs may present in an unusual manner with predominantly neurological manifestations such as acute confusion and seizure. In patients with unexplained acute confusional state the possibility of an AAD should be considered in the differential diagnosis. Bedside TTE has a limited sensitivity but high specificity in diagnosis of Type A AD and its early utilization may facilitate timely diagnosis improving outcome. Given the high specificity of TTE and time-dependent survival in Type A AD, institutional protocols to expedite the transfer to the operating room without waiting for CT confirmation might be considered.

BackgroundPesticide poisoning is a global public health problem. Annually, 3 million people are hospitalized due to pesticide poisoning with over 250,000 deaths all over the world 1. With the growing population and rapid industrialization in Qatar, there has been a natural increase in pesticide usage and hence, exposure amongst the workers handling them. It is therefore vital to not only understand the existing knowledge, attitudes and practices about handling pesticides, but also to explore the effectiveness of measures like education and personal protective equipment on the general well being of the workers. We hypothesize that training the workers to handle pesticides is vital in maintaining high safety standards, thereby preventing associated toxicity while handling them that the use of personal protective equipment (PPE) improves the general health of pesticide handlers in the long run.Methods100 municipality employees in Qatar who work with pesticides, were interviewed in person by trained bilingual staff using a structured questionnaire model (Table 4). The questionnaire included basic demographic data, questions related to methods of pesticide storage, retrieval, application and disposition, usage of PPEs, adherence to safety practices and views of the worker on the company safety protocols and their implementation. The data was then entered into excel format and analyzed using descriptive statistics and associations inferred by odds ratios.ResultsThe mean age of the workers was 37.4(SD-9.9)(Table1). Amongst workers nearly 2.9 % of them who did not use personal protective equipment visited hospital annually when compared to 1.4% of workers who used personal protective equipment (Table 2). Of the interviewed workers 81.1% did not know the contents or the name of the pesticides they were handling at work (Table 3). Unsafe behaviors such as preparation of pesticides at the site of its usage rather than in a specified preparation room (29.6%), noncompliance with wearing protective clothing (38.8%), handling of drinking water (22%) and food (10%) on site where pesticides are used and not washing clothes every day after work (45.9%) were observed. Around a quarter of the interviewees did not receive any training on preparation and handling of pesticides (Table 3). Workers who received training in pesticides usage were more likely to be aware of its effects on the environment (61.6%)(OR–3.9), less likely to eat or drink while handling pesticides(83.6%) (OR–4.3) and more likely to give household members appropriate instructions prior to application of pesticides (90.4%)(OR–5.0)(Table3).Workers who did not wear special protective clothes at work were found to be, more than twice as likely to visit hospitals per year, than those who wore(RR-2.2)(Table3). A third of the workers were not aware if their company had safety protocols in place, whereas a similar proportion felt no such protocols exist.ConclusionUnsafe practices were found to be significantly common amongst the personnel using pesticides in Qatar. Workers who received prior training, handled pesticides with better safety standards, highlighting the importance of training in pesticide handling. Wearing protective clothing most likely has a positive impact on the general well being of the workers.KeywordsImproved safety standards, municipality workers, pesticide exposure, protective clothing.Resources 1-World Health OrganizationThe Impacts of Pesticides on Health: Preventing Intentional and Unintentional Deaths from Pesticide Poisoning (fact sheet) 2- Gunnell, David and Eddleston, Michael. “Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries.” International Journal of Epidemiology 32 (2003): 902–909.Table 1 (DEMOGRAPHIC DATA) Demographic variables (n = 100) Percentage* Age Less than 20 1 21 to 35 48.9 36 to 50 36.7 More than 50 13.3 Mean 37.4 years Education Primary 33.7 Secondary 44.9 Not educated 11.2 Other 8.2 Number of years working with pesticides 10 32.7 Living with Family 14.3 Friends 30.6 Colleagues 54.1 Children 0.00 Other 2.0 *Total may not be 100% if there were missing valuesTable 2 (Comparison of variables for those wore special protective clothes to those who didn't) Variable Wore Special protective clothes (n,%) Did not wear(n,%) Number 59(59) 38(38) Age(mean) 37.4 37.5 Education Primary 27(45.8) 5(13.2) Secondary 20(33.9) 24(63.2) Not educated 8(13.6) 3(7.9) Years Working with pesticides 10 20(33.9) 11(28.9) Co morbid conditions 16(27.1) 9(23.7) Knowledge on content of pesticides Yes 7(11.9) 11(28.9) No 52(88.1) 27(71.1) Any training received? Yes 46(77.9) 27(71.1) No 13(22.0) 11(28.9) Average hospital visit/year 1.4(0.8–1.9) 2.9(1.9–4.1)Table 3 (ODDS RATIO) Variable Trained in pesticides (n = 73) Not trained in pesticides (n = 24) Odds Ratio with 95%CI Workers view on effect on environment YES 45 7 3.9(1.4 to 10.6) NO 28 17 Do not handle food/water at site 61 13 4.3(1.6–11.9) Wear special clothes 46 13 1.4(0.6–3.7) Knowledge of contents in pesticides present 16 2 3.1(0.7 – 14.5) Instruction to Household members 66 15 5.7(1.8–17.6) Washing clothes after work 40 13 1.02(0.41–2.59) Average visits to hospital/year 2.05(1.35–2.77) 2.04(0.68–3.41)Table 4 (RESPONSE TO QUESTIONNAIRE IN PERCENTAGE) Affirmative response Do you know the contents of the pesticide you are using? 18.4 When spraying inside do you give any instructions to the household members? 82.7 If yes what are they? Stay away from home 56.3 Don't prepare food at home 7.5 Don't get into the room for a specified period of time 35 Pesticides are poisonous 1.3 Where do you prepare the pesticides? On site 29.6 Comes prepared 3.1 Preparation room 58.2 Other 0.00 Did you receive any education on how to prepare/apply the pesticides? 74.5 If yes, who educated you? Foreman 19.7 Supervisor 40.9 Senior co worker 27.3 Other staff 12.1 When were you educated? At the start of job 55.3 Periodically 28.7 Where do you store the pesticides? Home 0.00 At the site 15.3 Buy and use immediately 1.0 Specific store 83.7 How do you dispose the containers? Yourself 15.3 By the company 73.5 Other 6.1 Do you wear special protective clothes, while using the pesticides? 60.2 Do you wash your clothes daily after work? 64 Do you wash them separately? 59 Powder 75.5 Solid tablets 41.8 Spray 74.5 Liquid 26.5 Smoke 33.7 Other 3.1 Which form of pesticide do you use out door? Powder 52.6 Solid tablets 38.1 Spray 82.5 Liquid 32.9 Smoke 60.8 Other 1.0 What personal protective equipment are you using? Masks 95.9 Gloves 93.9 Clothes 67.4 Shoes 83.7 Goggles 51.0 Other 2.0 Do you know the effects of pesticides? On Humans 81 On the environment 53 Pesticides can be absorbed through? Skin 46.3 Mouth 75.8 Inhalation 93.7 Other 6.3 Pesticides have? Only acute effects 42.3 Only chronic effects 14.4 Both 29.9 Neither 13.4 In case of accident exposure, what do you do? Wash with water and soap 78.5 Drink milk 13.3 Call ambulance 8.1 Go to hospital 11.2 Inform supervisor 7.1 How do you dispose this equipment? General waste 28.9 Specific site for disposal 25.3 Company does it 30.1 Plastic bags 6 Reuse/keep it to oneself 3.6 During application, do you? Eat 10.3 Drink 22.7 Both 1.0 None 76.3 After application, do you wash hands? 98.9 Do you have any co morbid conditions? 25.5 Are you taking any medications? 20.4 How many visits to the Health care/E.D/Admissions per year? 1.9(1.4–2.5) Are there any safety protocols at your company/work place? Yes 29.6 No 39.8 Don't know 30.6 Is your Company/Employer strict about compliance of safety protocols? Yes 48.5 No 23.7 Don't Know 27.8 If any untoward incident occurs, are they documented/informed to respective officials? Yes 43.9 No 43.9 Don't Know 13.3 Did you ever witness any case of sever morbidity or death in your company workers due to pesticide poisoning? Yes 17.4 No 82.7 Does your company provide compensation for pesticide poisoned workers? Yes 1.0 No 40.8 Don't Know 58.2.