Mycoplasma pneumoniae is a common cause of community-acquired pneumonia, and many extrapulmonary manifestations have been described, but rhabdomyolysis is infrequently reported in adults. Of the few cases that have been reported in adults, it was almost exclusively seen when pneumonia was present. We report a case of a 30-year-old male who came in with complaints of fever and myalgia for three days. Immunoglobulin M antibodies for Mycoplasma pneumoniae were positive and trending up, despite having no radiographic evidence of pneumonia on chest X-ray or CT scan. He was treated successfully with levofloxacin and intravenous hydration. Later, his condition was clinically and biochemically improved, and he was discharged. Our patient did not present with typical respiratory tract symptoms of a mycoplasma infection. In addition, there was an absence of pneumonia on imaging, suggesting that rhabdomyolysis secondary to mycoplasma might be underdiagnosed and go untreated in the setting of low clinical suspicion. Upon review of the literature, there is only one other case of mycoplasma infection where rhabdomyolysis occurred in the absence of pneumonia. However, the degree of rhabdomyolysis in our case was much more severe. Although rare, when faced with rhabdomyolysis, Mycoplasma pneumoniae should be kept as a differential diagnosis even in the absence of pneumonia on radiological imaging.

Objective Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for the treatment of hydrocephalus (HDC), especially in children. However, this is prone to many complications, and requires repeated surgeries, which as such increases the morbidity of the patients. It is estimated that majority of the complications occurs in the immediate post-operative period and the rate of complications decreases over the time, with no impunity to these, though. We conducted this study to know about the complications of VPS in the early post-operative period, in pediatric patients with hydrocephalus. Materials and methods This descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, between June 2019 and January 2020 (seven months). All patients with hydrocephalus below 12 years of age, operated for the first time were included after taking an informed consent, while those with repeated shunt procedures and elderly patients requiring shunt were excluded from the study. Patients’ details like age, gender, location, contact number, cause of hydrocephalus, date of shunt placement, type of surgery (elective or emergency) and any follow-up complications like failure, erosion, infections, ileus were noted on a predesigned proforma. After the surgery, patients were followed for a period of one month, and contacted either through the telephone or asked to visit in the outpatients on the specified days, and were evaluated for any shunt-related complications, and any of these complications suspected were further evaluated and noted. The data was analyzed using the statistical program SPSS version 19 (IBM Corp., Armonk, NY). Results are presented in the form of charts, tables and graph. Results During the study period, we evaluated a total of 151 patients; there were 78 (51.65%) males and 73 (48.34%) females with a male to female ratio approaching 1.1:1. The age range was from 22 days to 12 years. The mean age was 38.46 ± 7.53 months. The primary indications for the insertion of VP shunt were: congenital hydrocephalus in 70 (46.4%), post infectious hydrocephalus in 57 (37.7%), hydrocephalus due to tumor in 22 (14.6%), and post traumatic hydrocephalus in two (1.4%) patients. Among the total number of patients, 85 patients (55.6%) were done as elective cases and 66 patients (44.4%) were done as emergency cases. Complications were encountered in 30 patients (19.87%) during the follow-up of 30 days. Complications occurred between day 1 and day 20 of follow-up with a mean of 9.10 ± 1.69 2SD days. Conclusion VP shunt is the most widely used treatment for HDC, but is predisposed to complications and almost every fifth case of VP shunt comes across with complications. Shunt blockage, infections and abdominal wound-related complications are common earlier complications in pediatric patients with hydrocephalus.

Objective: Public hospitals have fixed days with allotted time slots during which to perform neurosurgical elective cases. If emergency operations or other events preempt these scheduled time slots, the patient remains hospitalized, waiting in queue for a new time slot. We conducted this study to determine the number of days patients remained admitted waiting for elective cases in a tertiary care public hospital, which operates on fixed days.Materials and methods: This cross-sectional study was conducted in the Department of Neurosurgery Unit B, Medical Teaching Institution (MTI) -Lady Reading Hospital (LRH), Peshawar. We reviewed the admission charts and discharge slips of all patients who were admitted and underwent operations between September 2018 and August 2019. A form was made and was completed with each patients' records like age, gender, number of days spent preoperatively and postoperatively and the total duration of stay, indication for surgery (spinal, cranial, peripheral nerve), etc. Patients who had undergone elective neurosurgical procedures were included while those who had undergone emergency surgeries or had expired during the hospital stay, had been discharged or referred to other centers were excluded from the study. All the data were entered into the statistical software SPSS version 22 (IBM Corp., Armonk, NY) and were converted into tables and charts.Results: A total of 1818 patients were admitted/discharged during the study period, and of them, 823 patients were admitted for elective neurosurgical procedures. There were 601 (73.7%) males and 222 (26.3%) females with a male to female ratio of approximately 3:1. The age range was from 09 days to 72 years and was further subdivided into six groups. The procedures were broadly divided into cranial, spinal, related to hydrocephalus (HCP)-related, and miscellaneous. Cranial procedures comprised of surgeries for brain tumors, transsphenoidal operations, vascular procedures for aneurysms, and nerve decompressions, and they comprised about 29.43% (n=244) while spinal procedures accounted for 317 (36.63%) procedures, the rest were related to HCP and miscellaneous. Preoperative and postoperative stay durations were calculated and then added to determine the total stay durations and were further stratified for the specific procedures and categorized into days and weeks. About 58.26% (n=143) of cranial cases, and 156 (49.36%) of spinal cases, 37.57% (n=65) of HCP-related cases, and 36.66% (n=41) of cases in the miscellaneous group had a duration of stay between eight days to more than three weeks.

Objective:  To know the incidence of CSF leak and role of tincture benzoyl in the management of CSF leak after the repair of congenital spinal deformities like myelomeningocele, meningocele and tethered cord syndrome.Materials and Methods:  All patients who were operated for congenital spinal surgeries in the form of MMC, Meningocele and TCS by a single surgeon were followed for a minimum of 3 months. Patients with already CSF leak/ruptured MMC prior to surgery were not part of the study. The particulars like gender and type of surgery, days since first surgery, associated infection, hydrocephalus and type of management were noted on a proforma.Results:  A total of 73 patients with spinal dysraphism were operated during the study period and of them about 13 patients returned with problems of the CSF leak. The mean duration and duration since the CSF leak was from 6 days to 16 days. Among them, 10 patients had an MMC repair and one patient had TCS release, while 2 patients were having meningocele repair. The patients were stitched and one patient was re-operated two times for repair of CSF leak. Two patients had a CSF leak along with post op signs of HCP that settled by placing a shunt along with primary repair of the wound reinforced with tincture benzoyl in a single setting. Conclusion:  CSF leak is a common complication following repair of spinal dysraphism and most patients can be managed with the application of tincture benzoyl alone or after simple skin reinforcement.

Objectives: To know about the causes of hydrocephalus (HDC) among thedifferent age groups. Study Design: Cross sectional study. Setting: Department of neurosurgeryPGMI/LRH. Period: August 2012 to September 2013. Materials and Methods: The operativerecords and the admission records of all the patients who were admitted and operated duringthe study period were checked. All the patients undergoing surgery for hydrocephalus wereincluded in the study and those patients who had undergone surgery for other reasons wereexcluded from the study. Patient s who had a repeated surgery for hydrocephalus were alsoexcluded from the study as well as those who were re-admitted for shunt related or surgeryrelated complications. The age, gender, and the radiological diagnosis of hydrocephalus wasrecorded on a designed proforma. All the patients were grouped into two that is above andbelow 12 years. Etiology wise HDC was classified as either congenital, post-infectious, tumorrelated, post trauma or miscelenous. The data was entered and analyzed using SPSS version16. Results: A total of 634 admission for Hydrocephalus were reviewed. 387 patients fulfilledthe inclusion criteria. There were 209 males and 178 females. The age range was from 1 monthto 69 years and the mean age was 8±4.6 years. There were 67.67% of the patients in the groupI while 33.33% of patients in the Group II. There was almost equal distribution on in the groupII based on the age difference. The major causes in the group I were the congenital, postinfectious, and tumor related while in the group II the main causes were the PIH, post tumor andthe post hemorrhagic. Conclusion: The most common causes of the HDC in the pediatric agegroup are the congenital, PIH and tumor related. In adults the most common causes of the HDCare the PIH, post Hemorrhagic HDC and tumor related Hydrocephalus.

Objectives: To know about the findings on fundoscopic examination in patients complaining of primary headache presenting to the Neurosurgical Outpatient Department (OPD). Study Design: Cross sectional study. Setting: Neurosurgery unit of Govt. Naseer Ullah Babar Memorial Hospital, Kohat Road, Peshawar. Period: December 2016 to December 2017. Materials and Methods: All patients presenting to the Neurosurgical OPD with complaints of headache on whom a fundoscopy was done, were included in the study. The age, gender, duration of symptoms, findings on the fundoscopy, and the need for further studies i.e. CT brain, were noted on a proforma. Any positive findings on fundoscopy were further referred to and evaluated by an ophthalmologist under the slit lamp. All patients with history of recent trauma, focal neurological deficit, and those who had undergone brain imaging were excluded from the study. Consent was taken from all the patients. The data was analyzed by SPSS version 19, and was expressed in the form of tables and charts. Results: A total of 19,000 patients were evaluated in the Neuro-OPD during study period, and 1086 patients were having headache.  Majority of the patients were females with a number of 619 (56.99%), while 447(43.01%) were males. The male to female ratio was approaching 1.38:1. Age range was from 9 to 62 years and the mean age was 37 years. Duration of symptoms was from 20 days to 12 years with a mean duration of 9 months. Positive findings were noted in a minority of patients, 2.5% (n=28); including pappiledema, diabetic and hypertensive changes. Subsequent Brain imaging was done in 93(8.5%) patients, majority of them were on patients' request, and only 7 patients were having an intracranial lesion. Conclusion: A minority of patients with headache without any neurology had intracranial lesion. However, the importance of fundoscopy cannot be overruled, and should be performed in every patient with headache.

Platelet hyperactivity may be involved in the pathogenesis of both thrombogenesis and hypercholesterolemia. The cholesterol-enriched states may contribute to accelerated development of atherosclerosis. The effect of high cholesterol on platelet activation and on inhibition by coagulation factor Xa, was studiedin vitro. Incubation of normal platelets (n=20) with cholesterol-rich dispersion resulted in a small increase of platelet aggregation (PA) and thromboxaneA2(TXA2) synthesis when compared with platelets incubated with cholesterol-normal dispersion. In hypercholesterolemic patients (n=20), ADP-induced PA andTXA2synthesis showed only small increases over normal controls. Addition of factor Xa (1 unit/mL) prevented the ADP-induced PA and markedly inhibitedTXA2synthesis in normal platelets (1.3±0.2and8.7±2.0pmolTXA2/108platelets, with and without factor Xa, resp.). However, factor Xa failed to significantly suppressTXA2synthesis in cholesterol-incubated normal platelets (9.5±1.4and11.8±1.3pmolTXA2/108platelets, with and without factor Xa; resp.,P=NS) as well as in platelets from patients with hypercholesterolemia (8.6±4.0and10.9±4.9pmolTXA2/108platelets, with and without factor Xa; resp.,P=NS). Exposure of platelets to high cholesterol concentrations,in vitroandin vivo, marginally increased PA andTXA2synthesis but resulted in loss of responsiveness to factor Xa, which could significantly contribute to platelet activation in hypercholesterolemic states.

Background and objective Low back pain (LBP) and sciatica are major healthcare issues globally. Since patients may seek various ways to cure their ailments, these conditions are managed not just by physicians, but many other health-related professionals provide alternative treatment options for it as well. We conducted this study to examine a local subset of patients who used stabbing their back and legs as a treatment option for curing LBP and sciatica. Materials and methods This cross-sectional study was conducted in the outpatient clinic of the Neurosurgery unit of Government Naseer Ullah Babar Memorial Hospital, Peshawar, Pakistan, from July 2019 to March 2020. Patients who presented to the outpatient department (OPD) with complaints of LBP with or without sciatica, with a history of invasive therapy in the form of stabbing the back or leg, or drawing blood from the veins of the lower limbs, were included. All other patients with LBP seeking neurosurgical advice were excluded from the study. The study was approved by the management of the hospital and informed consent was obtained from the patients before interviewing them. Special permission was taken for publishing the photographs. The demographics and clinical information related to patients, such as age, gender, duration of symptoms, time since the local therapy, particulars of the treatment provider, any relief experienced by the patient, duration of relief, the patient beliefs/notions about the therapy and disease, and education level of the patients, were recorded on a predesigned form after taking informed consent. The study was done on purposive sampling. The data was presented in tables and charts and was analyzed using SPSS Statistics version 20 (IBM, Armonk, NY). Results During the study period, more than 8,000 patients visited the neurosurgical OPD, and the majority of them (>70%) sought treatment for LBP and sciatica. Of them, around 130 patients had a history of undergoing some alternative therapy that is not scientifically proven, and it was either in the form of stabbing the back or drawing blood from the veins in the lower limbs. Amongst these patients, almost 80% were males and 20% were females who had undergone this kind of treatment. The age range among the cohort was 25-68 years and the mean age was around 43 years. The duration of symptoms ranged from two months to nine years, and the time since the therapy and patient seeking medical advice ranged from three months to 4.5 years. The treatment had been provided by a local individual who did not hold any medical degree according to the patients in 100% (n=130) of the cases; 67% of patients felt they had experienced some relief from the therapy for a short period, which ranged from three days to one month. About the condition, none of the patients seeking the therapy knew it was nerve-related and were often confused about the term rugg (vessel in the native language) but could not differentiate it from the...