ECT was introduced for schizophrenia but it is an effective treatment modality for depression-Iqbal Afridi


 RUNS meeting at JPMC

ECT was introduced for schizophrenia but
it is an effective treatment modality
for depression –Iqbal Afridi

FDA has approved DBS for essential tremors 
& Parkinson’s disease-Khalid Sher

In future it will be used increasingly for functional
movement disorders
 with trend towards earlier intervention

KARACHI: Research & Updates in Neurosciences (RUNS) organized a meeting at JPMC on July 21st 2018 which was very well attended by Neurosurgeons, psychiatrists, Neurologists besides postgraduate students. The speakers included Prof. Iqbal Afridi Prof. of Psychiatry, Prof. Khalid Sher Prof. of Neurology at JPMC besides Prof. Rashid Jooma former Prof. of Neurosurgery at JPMC. The meeting was hosted by the Dept. of Neurosurgery headed by Prof. Raza Rizvi and his team.

Welcoming the participants Prof. Lal Rehman said that the objective is to provide a forum for sharing knowledge and experience among colleagues in neurosciences. It is also very helpful for the postgraduate trainees.

Prof. Iqbal Afridi was the first speaker who talked about Co-morbid depressive disorders. He pointed out that there are some grey areas between neurosurgery and psychiatry. Mind and body functions together and we have to find out areas where we can work together. Unfortunately we have divided body into systems which is the drawback of modern medicine. He opined that we should not separate body from soul. There is a lack of recognition of seriousness of co-morbidity or inadequate understanding of holistic approach. Mental illnesses also lead to physical illness. Physical diseases are complication of psychiatric disorders. We recently conducted a study which enrolled 5,126 patients which showed that 82.5% also had co-morbid diseases like anxiety, depression and stress. Many diseases are interlinked. ICD-10 and now ICD-11 is expected soon covers all the diseases. Neuropsychiatric symptoms include irritability, mood disorders, apathy, and poor memory search. Depression as a co-morbidity results due to reduction in treatment adherence, poor prognosis, impairment in functioning, stroke, depression, anxiety, psychosis, mania and aggression etc. Patients go into depression after spinal surgery. Now it is agreed that no department will undertake psychosurgery unless the decision is taken in a joint Board of psychiatrists, neurologist, and neurosurgeons.

Continuing Prof. Iqbal Afridi said that studies have shown that if the stroke has left side lesions, the patient suffers from depression and has higher mortality. In post MI depression increases. Often patients come with vague presentations when they are suffering from depression. Hence it is important that one must look for psychological health as well. Educate the patient, ask them to have exercise, advice on sleep hygiene, participate in social activity. Advise on stress management and time management as well as psychotherapy which provides the patient an opportunity for ventilation. Behaviour therapy works and it has a therapeutic potential. ECT was though introduced for schizophrenia but it is a method of choice in depression as well. We now have about thirty eight anti-depressants in the market hence one has to be careful while selecting an effective anti-depressant. It is an art. He further stated that the patient should provide all the details to the treating physician, if a female is pregnant, she should not hesitate to share this information with her doctor as he will then prescribe drugs which are safe in pregnancy. In our department we have prepared detailed guidelines for prescribing drugs to special group of patients which are prominently displayed. It is criminal to prescribe Valporate to patients suffering from mood disorders, he added.

Prof. Khalid Sher was the next speaker whose presentation was on functional neurosurgery in neurosurgical disorders. This, he stated, was a new trend in neurosurgery and it helps those who are suffering from terrible disorders like tremors, epilepsy, Parkinson’s disease. We deal with abnormal brain functions. There are different strategies to treat them which include neuro modulation, spinal cord stimulation and focused ultrasound. In neuro modulation we block neuro signals to the brain. He then talked about Deep Brain Stimulation (DBS), Vagus Nerve Stimulation and Transcranial Magnetic Stimulation (TMS).

DBS, Prof. Khalid Sher said has some problems like infection, high cost, it is a scary procedure, size of the implant and it also needs frequent change of battery. With Transcranial magnetic stimulation there is 40% reduction in seizures. Vagus Nerve Stimulation also offers many advantages. FDA has approved Deep Brain Stimulation for essential tremors and Parkinson’s disease. In early Parkinson’s disease it is used very effectively. He however, made it clear that these patients will never be off medication, the dose of drug may be decreased. It is important to educate the patient while family support was also vital. He was of the view that we need specialized centers for DBS to ensure that follow up facilities are available. In partial tremor control, there is tremendous improvement in quality of life. However, DBS does not help in Gait balance, cognitive problems and depression. Hence, it is important that the patients have realistic expectations from this treatment modality. Quality of life does improve as compared to best medical therapy. FDA had approved DBS for essential tremors in 1997. He also discussed the targets for tremor control. In Dystonia, the device can be used if the patient has medially resistant symptoms. Younger patients may have better outcome. It may also improve pain in cervical dystonia. Effects of stimulation are not seen immediately but it takes some time. DBS also does not cure dystonia. Symptoms might progress despite therapy and it may not improve speech and swallowing. He laid emphasis on accurate surgical DBS placement and optimal DBS programming. One has to manage the side effects and ensure education and support of the patient. In the days to come DBS will be used increasingly for functional movement disorders and there will be trend towards earlier intervention.

This was followed by a 3D presentation on Neuro Anatomy by Prof. Rashid Jooma. With the help of numerous slides he discussed in detail the language pathways, visual pathway, commissural pathways, projection pathways, cortical mantle, DTI tractography and optic radiation.

This was followed by a few case presentations by various speakers. Dr. Abid Saleem from NCCI discussed Tenaunay syndrome and its effective treatment with Gamma Knife Radio surgery. So far only five cases of KTS have been reported in medical literature and this was the first case reported from Pakistan, he remarked. Prof. Shams Raza gave details of the forthcoming annual neurosurgical conference being organized at Nawabshah besides presenting a case of a patient who reported with pain in left leg. On investigation, tumor was found which was effectively excised. Dr. Sanaullah described the Axe injuries, their management and opined that since it was a dangerous weapon its easy availability should be controlled. Dr. Zaheer Shibli also presented an interesting case of a twelve years old patient who came with severe headache and loss of vision and was managed effectively.

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