Happy New Year,

We are opening Our Brand New Stroke Unit at Coptic Hospital.
From now on we are going to feature the Unit, and document its development.
Please follow and support us by crossing your fingers.

J.S.Bach Piano Concerto in D Minor D Minor BWV 1052 Polina Osetinskaya A...

Friedrich Gulda & Claudio Abbado - Mozart: Piano Concerto K488

https://worldstrokeorganization.blogspot.com/2018/06/new-icd-11-stroke-classification-will.html

http://www.world-stroke.org/

https://www.movementdisorders.org/MDS.htm

We are near to finalize the launch of our Stroke unit and first ever Alteplase ready team in Equatorial Africa.

We would invite Kenyan emergency services, radiologists, nurses, neurosurgeons, and vascular surgeon for our preliminary discussion panels, and training sessions.

The timetable of sessions will be available in this page, on my personal blog, and Coptic Hospital web-page.

Simeon ten Holt - Canto Ostinato for two pianos and two marimbas

Igor Stravinsky - Tango for Piano

Solo & Indrė. Full Album

Evidence Based Treatment of Idiopathic Intracranial Hypertension. (IIHT)

Andras Rozsa, MD PhD, Coptic Hospital, Kenya

Statement of problem:

Idiopathic Intracranial hypertension (formerly benign intracranial hypertension or pseudotumor cerebri) is a serious disorder with therapeutic uncertainties. It may affect young obese women, with body mass index around 40, and presents with headache, visual obscurations, back pain, and pulsatile tinnitus. One to four per one hundred thousand people may be affected every year. The condition endangers vision. There is a lack of uniform agreement concerning medical management with diuretics; and there is a lack of guidelines concerning the necessity and timing of surgical interventions.

 In a 2015 Cochran Review concluded that “although…..the included RCT showed modest benefits for acetazolamide for some outcomes, there is insufficient evidence to recommend or reject the efficacy of this intervention”.

Purpose of this Study:

To find any new evidence based results published since the Cochrane Database Review of IIHT released in 2015 August.

Methodology and Theoretical Orientations:

Online research of MEDLINE, Cochrane Library and CENTRAL, MEDSCAPE, PLOS, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform.

Findings:

New results of one trial were published in multiple articles: “Idiopathic Intracranial Hypertension Treatment Trial”. This was a randomized, double-masked, placebo-controlled study.

165 patients were enrolled with mild vision loss. 86 patients were randomized to acetazolamide, 79 to placebo group.

Quality of life questionnaire results reported improvement in visual field, and neck pain, pulsatile tinnitus, and dizziness/vertigo that outweighed the side effect of acetazolamide.

All 165 patients had lumbar puncture at enrollment, 85 at 6 month. There was an association between cerebro -spinal pressure (CSFp) and Frisen papilla edema grade (FPG) at baseline.  At 6 months, acetazolamide had similar effect on CSFp in subjects with high FPG and in subjects with low FPG . Only modest association was found between CSFp and FPG.

In patients with IIH and mild visual loss the use of acetazolamide with low-sodium weight -reduction diet compared with diet alone resulted in modest improvement in visual field function. The study found profound effect of weight loss on outcome.

89 (43 acetazolamide, 46 placebo) of 165 subjects meet criteria to enroll to asses papilla edema to SD-OCT (spectral domain optical coherence tomography). Acetazolamide group had significantly greater reduction of retinal nerve fiber and total retinal thickness.

Conclusions and Significance:

In the light of new publications it is still not clear the medication or weight loss resulted in positive outcomes. Only mild cases were enrolled in the cited study. There are no data regarding drug adverse affects, neither explanations of high drop-out rate. No CSF studies results provided except changes in opening pressure. Further RCTs needed to provide conclusive evidences of interventions.

References:

1.       Piper RJ, Kalyvas AV, Young AMH et al: Interventions for idiopathic intracranial hypertension (Review) Cochrane Database of Systematic Reviews 2015, Issue 8. Art No.: CD003434

2.       Effect of Acetazolamide on Visual Function in Patients With Idiopathic Intracranial Hypertension   and Mild Visual Loss. The Idiopathic Intracaranial Hypertension Treatment Trial. The NORDIC   Idiopathiac Intracranial Hypertension Study Group Writing Committee.  JAMA. 2014; 311(16): 1641-1652

3.       Kattah JC, Pula JH, Mejico LJ et al: CSF pressure, papillaedema grade, and response to acetazolamide in the Idiopathic Intracranial Hypertension Treatment Trial. Journal of Neurology. Published online 10 July 2015

4.       Mall M, Kupersmith MJ, Kieburtz KD et al: The Idiopathc Intracranial Hypertension Trial. JAMA Neurol. 2014 June; 71(6): 693-70 

      The OCT Sub-Study Committee and the NORDIC Idiopathic Intracranial Hypertension Study Group. Papiledema Outcomes from the OCT Substudy of the Idiopathic Intracranial Hypertension Treatment Trial. Ophtalmology. 2015 September; 122(9): 1939-1945

      Bruce BB, Digre KB, McDermott MP et al: Quality of life at 6 month in the Idiopatica Intracranial Hypertension Treatment Trial. Neurology. 2016 November; 87: 1871-1877

      Wall M, Johnson CA, Cello KE et al.; for the NORDIC Idiopathic Intracranial Hypertension Study Visual field outcomes for the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) Invest Ophtalmol Vis Sci. 2016; 57; 805-812.

driving a coach -"four at hand" - in Nairobi

Arvo Pärt Fur Alina 1976

Carey Bell - Live at the International Jazz Festival (Bern, Switzerland ...

Repose

With coach in the ‘Puszta’. The autumn in the ‘Great Hungarian Plain’

In October, from the palette of the nature, the autumn paints the ‘great Hungarian’ plain from lush green into gold, brown, yellow and amber. Lucky was I to be invited to the cottage of ’Jaszkarajeno’ by Sandor Galambos to visit the National Coach Riding competition in Hungary. The Galambos family is one of the oldest horse breeding family, and he and his son are winners of many European coach riding competitions. 

Linguistics shows that the origin of the word ‘coach’ and its equivalents in many European languages is the Hungarian word ‘kocsi’-he says. It is derived from the wagon of ‘Kocs’. The village of ‘Kocs’ in Hungary is considered to be the home of coach builders who build the first light and fast carriages.  The colorful world of carriage as part of everyday life has disappeared in inverse ratio to the rapid advance of motorization. But an increasing number of horses are kept for sport and recreation. Equestrian sports have made remarkable progress during the last few decades and their popularity has increased in our motorized world. One of the newest of the equestrian sports, carriage-driving, has recently been accorded official recognition by the International Equestrian Federation. Carriage-and-pair championships and four-in-hand World Championships has been held in every two years. Carriage-driving competitions last three days, on the first day there is presentation and dressage, on the second day the marathon, and on the third day the obstacle driving. It is very complex challenge, which requires much knowledge, attention and training.

Because it is a relatively new sport, which is a short time in horse breeding, means that we cannot even speak about individual breed especially suitable for driving competitions. The horses, other accessories such as harness, vehicle and its fitting are of vital importance. We usually use the Arab, the Lipizzaner, the Nonius and the Hungarian half-breeds, but with some refinement in breeding, Mr. Galambos explains. In selecting them, care must be taken regarding harmony, since vehicles should not only meet the demands of practicability, but also those of aesthetics. According to their usage, present day competition vehicles are divided into two groups: road carriages and cross-country carriages. As carriage-driving is a formal event, dark clothing is considered to appropriate to wear. It is very much the driver’s favour if his dress matches the colour of the covers and the grooms’ outfit. If the assistant driver wears national costume, the driver himself should be dressed in dark gray or black. The costume of the grooms and of the assistant drivers can be proper coachman’s livery or the original national costume of a particular geographic region. The assistant driver of a carriage-and-pair may be attired in a sporting style similar that of the driver. Ceremonial dress is always close fitting, the boots have seam on the side, the shafts are stiff and the counters low. The characteristic broad-brimmed hat is adorned with ostrich feathers. A fringed silk tie and brown leather gloves complete the outfit. The first day, the presentation is actually a kind of ‘beauty contest’ in which a three-member jury judges the competing teams. A very essential aspect is that horses of a team should be uniform in colour and size. The harness should be put on correctly and the team has to be fully equipped. The driver and the grooms should be dressed according to the rules. All the parts of the carriage, and accessories like shabracks, blankets, upholstery, dress, should coordinate in colour and style. Further points are awarded to the trimness of the team, i.e horses, harness, carriage, dress, boots and shoes should all be in the best condition.

During cross-country driving or marathon - which is the second day of the competition - the distance to be covered is between 20 and 30 km on very different kind of road: lose sand, gravel, loess or plain, hilly and rocky ground and sometimes even mountains.

The third day of the competition is the obstacle driving. The course of obstacle driving is either on turf or in a stadium. The obstacles to be negotiated in the sequence are: gates, U or Z-formed passages and there are sometimes water-ditches and platforms. The rather spectacular nature of obstacle driving gives it a high entertainment rating, and it usually attracts several thousand spectators. It is important to be prepared for this, as no driver is without nerves - says Mr. Galambos and instead of inviting us into a race coach, with a smile he whisked us into a ceremonial coach to enjoy the stunning autumn sunset of the ‘Puszta’. We just can not resist sharing the beauty and joy of  driving coaches.

African jazz-funk (2)

And finally for Neurologist on tropics:

And my third favorite new book

Another recommended book:

Neuroanatomy Text and Atlas, Fourth Edition

Neuroanatomy Text and Atlas, Fourth Edition

A delicacy for gourmands - really wonderfully illustrated

FRIEDRICH GULDA - Mozart Piano Concerto # 26 (Coronation) Munchner Phil...

Friedrich Gulda: Beethoven - Piano Concerto No. 5 in E flat major Op. 73

Friedrich Gulda Mozart Sonatas KV 332, 375, 457 München live 1990

FRIEDRICH GULDA - MOZART PIANO CONCERTO # 20 / Munic Philharmonic Orchestra

Joe Zawinul - Full Concert - 08/16/97 - Newport Jazz Festival (OFFICIAL)

Fatoumata Diawara - Fatou (Full Album)

Diana Krall - Full Concert - 08/15/99 - Newport Jazz Festival (OFFICIAL)

Minimal

Water themes

Kenya Coast

Short guide for students, how to develop a Study:

Short guide for students, how to develop a Study

During the clinical rotations, you are expected to finalize your research study and develop a complete dissertation and a one or maximum two page thesis. In this section we try to assist your work by giving you some practical advice on how to do this task.

At the end of the clinical rotation course, students have to submit a dissertation and thesises. We understand that most of our students are experiencing their first step in independent study planning and implementation, and they may have little experience in scientific publication, or in dissertation preparing procedures.

Most medical universities do not provide education on how to prepare a scientific paper. USAIM is in a good position because you have worked before on your other projects, and our Syllabus also provides help to understand the general requirements of study design, management and requirements about medical publications. Still, for the novices it can be a painstaking process with a lot of frustration to learn the methodology to design and perform scientific research and prepare a manuscript for publication readiness. It is hard to find really unselfish peer or senior mentor assistance.

On the other hand, international criteria and agreements exist on how to present your results. We expect our students to follow these formal requirements. For the formal expectation for your dissertation here we are featuring the digested and short version of the expectations of the JAMA and the British Medical Journal. This description might be “high flying” for requirements for medical students, but we expect you to follow the general aspects of a publication, especially the IMRAD structure, with a correctly chosen title, perfect abstract and most importantly, with genuine authorship. Please note that plagiarism is not tolerated and you might risk your right to graduation.

American English is slightly different than British English, for example in punctuation and transcription of Latin terminology. Both languages can be rightly chosen, but once a decision has been made you should consistently use the chosen way for grammar.

You might get further help if you consult with the web page either of the JAMA or the BMJ in any case of doubt or uncertainty. We also strongly recommend consulting with handbooks if needed, and following the methodology of the evidence-based medicine. Please ensure that anything you submit conforms to the uniform requirements for manuscripts submitted to publication in biomedical literature. 

Uniform requirements for manuscripts submitted to biomedical journals are also published in:

International Committee of Medical Journal Editors. Med Educ. 1999; 33(1):66-78
or: http://www.icmje.org/index.html

(Please note that the enclosed material is only referring to the uniform requirement for manuscripts and is edited for simplicity. This document cannot include a comprehensive review of the scientific publication requirements.)

Formulation of Thesis:

The thesis should cover what your paper adds to the literature, and is for readers who would like an overview without reading the whole dissertation paper. It should be divided into two short paragraphs:

Paragraph 1:  What is already known on this subject?

In two or three sentences explain what the state of scientific knowledge was in this area before you did your study and why this study needed to be done. Be clear and specific, not vague. For example you might say: “Numerous observational studies have suggested that tea drinking may be effective in treating depression, but until now evidence from randomised controlled trials has been lacking; the only randomized controlled trial to date was underpowered and was carried out in an unusual population, did not use internationally accepted outcome measures and used too low a dose of tea.”
or: “Evidence from trials of tea therapy in depression have given conflicting results. Although Sjogren and Smith conducted a systematic review in 1995, a further 15 trials have been carried out since then…”

Paragraph 2:  What does this study add?

Give a simple answer to the question “What do we now know as a result of this study that we did not know before?” For example, “This randomized study suggests that tea drinking has no overall benefit in depression”.  Be brief, succinct, specific, and accurate.

You might use the last sentence to summarize any implications for practice, research, policy, or public health. For example, your study might have asked and answered a new question (one whose relevance has only recently become clear), contradicted a belief, dogma, or previous evidence, provided a new perspective on something that is already known in general, or provided evidence of higher methodological quality for a message which is already known.

Please define the clinical question in four aspects: patient, intervention, comparison, and outcome.

The thesises should show that you have searched for, cited, and summarized studies of appropriate relevance, design, and quality, and should state which bibliographic databases you have used. 

Authorship

The uniform requirements for manuscripts submitted state that authorship credit should be based only on substantial contribution to conception and design, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content on final approval of the version to be published.  And this can be only you.

All these conditions must be met. Participation solely in the acquisition of funding or the collection of data does not justify authorship. 

We want authors to assure us that they fulfill the criteria of authorship. In addition we want assurance that there is no one else who fulfils the criteria but has not been included as an author.

The Research and Its Presentation in the Dissertation:  ‘IMRaD’

The dissertation should report original research relevant to clinical medicine. They should follow the IMRAD style (Introduction, Methods, Results and Discussion) and should have a structured abstract.

If you are submitting a randomised controlled trial, please follow the CONSORT guidelines (http://www.consort-statement.org). If you are submitting a systematic review, please follow the QUOROM guidelines (David Moher et al for the QUOROM Group. Lancet 1999;354:1896-1900). And if you are submitting a study of diagnostic accuracy please follow the STARD guidelines (http://www.consort-statement.org/stardstatement.htm ).

We know that people do not read long papers unless they are very interested in the subject. So please try to make your paper concise, and make every word count. Think hard about what really needs to be in the paper to get your message across, and what can be left out.

Please provide all following dissertation items with your paper:

Title page

This should give the title of the paper, including the study design if the paper presents original research.

Structured abstract

No more than 250 words with the following headings and information: 

Objectives - a clear statement of the main aim of the study and the major hypothesis tested or research question posed. 

Design - including factors such as prospective, randomization, blinding, placebo control, case control, crossover, criterion standards for diagnostic tests, etc. 

Setting - include the level of care, e.g. primary, secondary, and the number of participating centers 

Use “Participants” instead of “patients” or “subjects”. Who, how selected, what entry and exclusion criteria used, how many entering and completing the study. Detail the interventions - what, how, for how long, etc. Detail main outcome measures - those planned in protocol, those finally measured (if different, explain why). 

Results - main results with (for quantitative studies) 95% confidence intervals and, where appropriate, the exact level of statistical significance. 

Conclusions - primary conclusions and their implications, and suggest areas for further research if appropriate. 

See: Haines RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ. More informative abstracts revisited. Ann Intern Med 1990;113:69-76

Qualitative research papers may need fewer headings in the structured abstract. Quality improvement reports have their own style of structured abstract.

The structured abstract for a systematic review or meta-analysis should have these sections: objectives, data sources, review methods, results, and conclusions.

Structured Discussion

We encourage, but do not require authors to write the discussion sections of original research papers in a structured way in order to minimize the risk of careful explanation giving way to polemic. We suggest that the discussion follows this structure:

a.       Statement of principal findings.

b.      Strengths and weaknesses of the study.

c.       Strengths and weaknesses in relation to other studies, discussing important differences in results.

d.      Meaning of the study: possible explanations and implications for clinicians and policymakers.

e.       Unanswered questions and future research..

Please also include: 

a.       Original data if you think they will help our reviewers.

b.      Copies of any non-standard questionnaires and assessment schedules used in the research. 

c.       Copies of patient information sheets used to obtain informed consent. 

d.      Details of sources of funding for the research, if any. (These are now published with all papers.) 

e.       Copies of related papers you have published. This is particularly important where details of the study methods are published elsewhere. 

Stylistic Advice     

 

Please write in a clear, direct, and active style. Many readers do not have English as their first language. 

Preferred dictionaries are:

Chambers 21st Century Dictionary for general usage

“Dorlands” for medical terms. 

Punctuation:

No full stops in initials or abbreviations. 

Minimal commas, but use commas before the "and" and "or" in lists: 

The bishops of Durham, Canterbury, Bath and Wells, and York were invited.

Use commas on both sides of parenthetical clauses or phrases, and with commenting clauses. 

Know the difference between defining clauses (no comma) and commenting clauses (commas needed):

Medical staff who often work overtime are likely to suffer from stress. 

Medical staff, who often work overtime, are likely to suffer from stress. 

Use commas before "and," "or," "but" in two-sentence sentences (when the coordinate conjunction joins two main clauses): 

Instead: Half received drug treatment, but their symptoms did not resolve more quickly. 

Half of the patient received drug treatment, but their symptoms did not resolve more quickly

Note that when a comma is used, both main clauses must have a subject:

Instead: The patients stopped smoking, and they felt better for it. 

The patients stopped smoking and felt better for it. 

Minimal hyphenation - use hyphens only for words with non-, -like, -type, and for adjectival phrases that include a preposition (one-off event, run-in trial). Not using hyphens will help you to avoid noun clusters

Quotation marks - please use double, not single, inverted commas for reported speech. Full stops and commas go inside quotation marks: 

She said, "We will." 

No exclamation marks, except in quotes from other sources. 

Reference numbers go after commas and full stops, before semicolons and colons. 

Minimal capitalization: use capitals only for names and proper nouns. Don't capitalize names of studies. 

Grammar

Published result present tense

Your results: simple past tense

Write in the active and use the first person where necessary. 

Try to avoid long sentences that have several embedded clauses. 

Gender: avoid "he" as a general pronoun. Make the nouns (and pronouns) plural, then use "they"; if that's not possible, use "he or she". 

Nouns and verbs should agree: 

The data are; None is... 

Organizations and groups of people take singular verbs: 

The government is; The team has researched...

Avoid noun clusters: 

"Patient in coronary care unit" rather than "coronary care unit patient." 

Watch out for "danglers" (unattached participles and misrelated clauses): 

Joining the service in 1933, his first post was... (the post didn't join the service) 

Joining the service in 1933, he was first posted to... (this is correct) 

Spelling

Decide American or English:  e.g. if your choice is BMJ recommended English or JAMA spelling, the followings should be considered:

aetiology                      etiology

oestradiol                     estradiol

anaemia                       anemia

haemorrhage                hemorrhage

practice (noun)

practise (verb)

Foetus and fetus are both acceptable in English, but “fetus” in JAMA spelling and the BMJ uses fetus too.  If British (BMJ style): use s-spellings:  minimise, organization, capitalization. Use English spellings for place names: Lyons, not Lyon; (see Whitaker's Almanac or Times Gazeteer) 

Abbreviations:

We allow minimum use of abbreviations because they ae hard to read and often the same abbreviation means different things in different specialities and contexts.

TechnicalTerms

Drugs should be referred to by their approved non-proprietary names, and the source of any new or experimental preparations should be given. 

Scientific measurements should be given in SI units, except for blood pressure, which should be expressed in mm Hg. 

Numbers under 10 are spelt out, except for measurements with a unit (8mmol/l) or age (6 weeks old), or when in a list with other numbers (14 dogs, 12 cats, 9 gerbils). 

Raw numbers should be given alongside percentages, and as supporting data for p values. 

References 

These should be numbered in the order in which they appear in the text. At the end of the article the full list of references should follow the Vancouver style.

Ref: “Uniform requirements for manuscripts submitted to biomedical journals” or: International Committee of Medical Journal Editors. Med Educ. 1999; 33(1):66-78

Please give the names and initials of all authors (unless there are more than six, when only the first three should be given followed by et al). 

Usual way of citations is that the authors' names are followed by the title of the article; the title of the journal abbreviated according to the style of Index Medicus; the year of publication; the volume number; and the first and last page numbers. 

References to books should give the names of any editors, place of publication, editor, and year.

Examples: 

21 Soter A, Wasserman S I, Austen K F. Cold urticaria: release into the circulation of histamine and eosinophil chemotactic factor of anaphylaxis during cold challenge. N Engl J Med 1976;294:687-90 

22 Osler AG. Complement: mechanisms and functions. Englewood Cliffs: Prentice-Hall, 1976.

Information from manuscripts not yet in press, papers reported at meetings, or personal communications should be cited only in the text, not as a formal reference.

Authors should get permission from the source to cite personal communications. 

Authors must verify references against the original documents before submitting the article.

Electronic citations

You may know of other websites that will interest people reading your article. If you know the web addresses (URLs) of those sites, please include them in the relevant places in the text of your article.

Tables, Illustrations and Photographs

Tables should be simple and should not duplicate information in the text of the paper. Illustrations should be used only when data cannot be expressed clearly in any other way. When graphs, scattergrams, or histograms are submitted, the numerical data on which they are based should be supplied; in general, data given in histograms will be converted into tabular form. 

Statistical Methods

Please define the methods and support them with references, describing in detail any that are not in common use. Consult with general guidelines on using statistical methods and interpreting and presenting statistical material, as well as specific recommendations on statistical estimation and significance.  

Also see: Altman DG, Machin D, Bryant TN, Gardner MJ (eds). Statistic with confidence 2nd edition. London: BMJ Books, 2000.

Randomised Controlled Trials

Please report these in accordance with the CONSORT (Consolidated Standards of Reporting Trials) statement.  This ensures that you provide enough information for editors, peer reviewers, and readers to see how the trial was performed and to judge whether the findings are likely to be reliable. 

Please provide the following, as described in the CONSORT statement: 

Five extra subheaded sections in the main text of the paper: protocol, assignment, masking, participant flow and follow up, analysis. 

A flow chart showing the progress of participants through the trial 

Systematic reviews and meta-analyses of randomised controlled trials

Please report these in accordance with the QUOROM (Quality of Reporting of Meta-analyses) statement (Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF, for the QUOROM Group. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Lancet 1999; 354:1896-1900. www.thelancet.com )

The structured abstract should have these sections: objectives, data sources, review methods, results, and conclusions.

Qualitative research

These reports may be difficult to fit into the IMRAD (Introduction, Methods, Results and Discussion) format for original research papers. You may find that presenting the results and discussion together, theme by theme, makes most sense: this is fine, but please ensure that the structured abstract matches the layout of the text.

Economic Evaluations

If you submit a paper reporting an economic evaluation please ensure that it follows the guidelines. These are: study design, data collection, analysis and interpretation of results.

Evaluating Educational Interventions

Many readers may not be familiar with methodologies used to evaluate educational interventions.
Two crucial factors in good studies are: 1./ the educational rationale behind the intervention is made explicit 2./ that the evaluation is planned in advance.