Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city

Pakistan Journal of Neurological Sciences (PJNS), Dec 2017

The burden of neurological disorders (NDs) in developing countries is 4-5%, compared to 10-11% in developed countries. This burden is rising in developing countries due to prolonged life expectancy, improved health facilities, easy access to diagnostic facilities, and a trend in urbanization. There is inadequate data about the epidemiology of major NDs in Pakistan and most available information are hospital-based estimations or physicians’ collected data.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1194&context=pjns

Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city

V O L . Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiar y carecenters of the city Ghulam Hussain 0 1 Shahid Mahmood Baig 0 1 PIEAS 0 1 Faisalabad 0 1 Pakistan 0 1 0 Government College University , Faisalabad , Pakistan 1 COMSATS Institute of Information Technology , Islamabad , Pakistan Follow this and additional works at: https://ecommons.aku.edu/pjns Part of the Neurology Commons Recommended Citation - Article 2 See next page for additional authors Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city Corresponding to: Ghulam Hussain, Department of Physiology, Liaquat Block, 1st Floor. New campus, Government College University, Jhang Road, 3800 Faisalabad. Contact: +923006654101 Email: The mortality rate and burden of disability caused by NDs is higher than any other major disease worldwide–25. The overall prevalence of NDs is 6.5% and incidence trends have shown an alarming rate of increase over time3. Demographic, geographic, and socioeconomic conditions are major factors that affect the epidemiology oNDs. Previous us research has shown that prevalence and incidence of NDs is positively correlated with the economic condition of a given country. The burden of NDs increases as a country expands economically3,6. In lower-income countries,the reported prevalence of NDs ranges from 4% to 5%,whileprevalence in countrieswith higher GDP is 10-11%2,3,7. The higher rate of NDs in developed countries may be due to their more robust system of public health services and healthrelated facilities that screen and provide health services for the average patient. It has been documented that 6.75% of the American population and6% of the Population have been diagnosed with NDs. In recent years, the burden of Nds in developing countries has continued to increase; this grow this correlated with increasing epidemiological data, prolonged life expectancy, improved health facilities, facilitated access to healthcare centers, provision of advanced diagnostic technology, and a trend in urbanization among the population. Although there are data regarding the incidence and prevalence of ND sin developing countries of Asia, such as China, India, and Sri Lanka, these data may not be generalizable to Pakistan, due to differing social, geographical, religious, cultural, and ethnic aspects unique to those countries. Therefore, it is necessary to conduct epidemiological studies in Pakistan to collect and analyze reliable data for this region of the world . The prevalence of Nds in India ranges from 967–4,070/100,000 with a mean of 2,394/100,000 population. Such prevalence indicates that over 30 million people are living with NDs in this country with the second largest population in the world. The prevalence of common disorders, such as stroke, epilepsy, tremors, Parkinson's disease (PD), and mental retardation, is not uniform across the different regions of the country . The overall crude prevalence of NDs in Saudi Arabia was reported to be 131/1,000population .Recent reports indicate about68.5/10,000 prevalence of NDs in the pediatric population of Saudi Arabia . Published data regarding the epidemiology of major NDs in Pakistan is limited, and most available information are hospital-based estimations or physician-collected data, limited to a few cities. These data are likely not nationally representative . In comparison to neighboring countries, it maybe possible to determine aggregation of the existing, disparate data sources. The existing information the prevalence of NDs in Pakistan based concerning the prevalence of NDs in selected cities of Pakistan indicate that the burden of NDs is a serious concern. Epidemiological data concerning selected Nds are available, but this information is limited to particular locations and, therefore, cannot be generalized to determine the overall burden of NDs in Pakistan nationally. Most available data are from the city of Karachi, while prevalence and incidence in the other mega-cities of Pakistan have yet to be investigated. In the present study, we focused our evaluation of NDs in Faisalabad, the third largest city of Pakistan. To our knowledge, this is the first study concerning the prevalence and burden of NDs at the leading tertiary care centers of this mega-city. MATERIALS AND METHODS In the present study, study subjects were recruited from the patient population at the outpatient neurology and psychiatry departments of Allied Hospital, DHQ Hospital, Aziz Fatima Trust Hospital, Faisal Hospital, and Al-Noor Hospital in Faisalabad, Punjab-Pakistan. The inclusion criteria for selecting the hospitals were that the facility was well-equipped, possessed functional basic and advanced facilities for diagnosis of complicated NDs, and had a sufficient patient population for recruitment at the outpatient facility. The selected tertiary care centers are the highest-volume centers in Faisalabad district. The health care centers were selected from4 different corners of the city in order to acquire representative data from each region of the district. Furthermore, a mix of government and private-sector hospitals were selected to ensure the in clusion of an economically divers ecohort that would be more representative of the population in general. A structured questionnaire was used to gather basic data about the patients receiving care in the selected hospital departments. The data were collected from March 2015 to May 2015. Prior authorization was sought from the hospital administration for collection of data. The physicians and psychiatrists of participating patients were requested to make a detailed diagnosis based on the available medical tests for the possible ND. Patients were interviewed and data were recorded on questionnaires. Patients undergoing their first clinical visit were excluded, as their clinical diagnosis may not have been fully determined. Patients with confirmed diagnoses were included in the study, and data were collected from the subjects after obtaining consent of either the patient or his/her care giver. The available record of medications and treatment was also collected for further verification as needed. Information about gender, age, marital status, type of disorder, familial history for the disorders of interest, and consanguineous marriage were collected for further analysis of related risk factors. INSTITUTIONAL REVIEW BOARD APPROVAL The Institutional Review Board (IRB) of Government College University, Faisalabad-Pakistan carefully reviewed and granted approval for this study. RESULTS The overall burden of NDs in Faisalabad District was assessed in the 3,068 study participants. The rate of each ND reported in this population was as follows: . depression 19.6% (n = 602), epilepsy 16.6% (n = 508), migraine 15.2 % (n = 466),disc prolapse 8.8% (n = 269), paralysis 8.5% (n = 262), trauma 5.3% (n = 163), P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S brain hemorrhage 5% (n = 153), PD3% (n = 92), schizophrenia 2.7% (n = 83), congenital anomaly 2.2% (n = 68), tumor 1.6% (n = 50), dementia 1.7% (n = 52), mania 0.8% (n = 25), acute psychological disorder 1.4% (n = 43), disruptive behavior disorder 0.6% (n = 19), bipolar affective disorder 0.7% (n = 22), and miscellaneous 6.2% (n = 191) (Figure 1). 6 . 20.0 19 .616 .521 25.0 tsn15.0 e it ap10.0 f o %5.0 0.0 The rate of Nds among the population varied by the towns of Faisalabad, with rates as follows, Lyallpurtown30.7% (n = 863), Jinnahtown15.0% (n = 421), Iqbal town 19.3% (n = 542), Madina town 17.7% (n = 498), Chak Jhumra town 2.2% (n = 63), Jaranwala Town 8.6% (n = 243), Samundri town 4.5% (n = 126), and Tandliyanwala town 1.9% (n = 54) (Figure 2). 8.6% 2.2% 17.7% 4.5% 1.9% 30.7% 15.0% 19.3% Layalpur Iqbal Town Jinah Town Madina Town Chak Jhumra Town Jaranwala Samundari Tandiyanwala Town There were 382 patients (27%) for which a family history of mental illness was noted. The percentage of patients with positive family history by disease category was 80% (n = 4)PD, 23.5% (n = 4) schizophrenia, 76.9% (n = 10) disc prolapse, 11.5% (n = 15) depression,30.8% (n = 37) epilepsy, and33% (n = 33) migraine Nds were more prevalent in the female group as compared to the male group in Faisalabad. Among the study population, 41.5% (n = 1300) were male gender and 58.5% (n = 1829) were female gender. Depression, migraines, disc prolapse, brain hemorrhage, PD, dementia, mania, and other mental illnesses were more common in the female group (67.1%, n = 444; 75.4%, n = 352; 61.7%, n = 262; 52.3%, n = 80; 63.0%, n = 58; 51.9%, n = 27; 60.0%, n = 15; 56.0%, n = 154, respectively) than in the male group(32.9%, n = 218; 24.6%, n = 115; 38.3%, n = 103; 47.7%, n = 73; 37.0%, n = 34; 41.8%, n = 25; 40.0%, n = 10; 44.0%, n = 121, respectively). Epilepsy, paralysis, and trauma were more common in the male group (53.0%, n = 269; 53.4%, n = 140; 55.8%, n = 91) than in the female group (47.5%, n = 239; 46.6%, n = 122; 44.2%, n = 72). The burden of schizophrenia, congenital anomaly, tumor, and dementia was approximately equivalent between the female group (50.6%, n = 42; 48.5%, n = 33; 50.0%, n = 25; 51.9%, n = 27, respectively) and the male group (49.4%, n = 41; 51.5%, n = 35; 50.0%, n = 25; 48.1%, n = 25, respectively). s t n e it a p f o % The study subjects were divided into 4 age groups, group I (10-30 years), group II (31-50 years), group III (51-70 years), and group IV (70-90 years),in order to capture the burden of ND sat early or late age onset. Groups I and II, covering the age ranges of 10-50 years, manifested a similar rate of ND burden (37.8% and 37.5%, n = 1073 and n = 1065, respectively). The burden was remarkably lower in age groups III and IV (20.7%, n = 587 and 4%, n = 115, respectively). Depression was higher in group II as compared to other groups. Majority of epileptic patients feel in younger age group as compared to older age group. Half of the patients with migraine were in group II 207 (45.1%), followed by migraine in group I 39.7% (n = 182). Disc prolapse was more common in group II 46.9% (n = 122)while group III manifested the highest value of paralysis 40.2% (n = 103).Trauma was more abundant in group I 40.6% (n = 63) than in any other group, while brain hemorrhage was mostly noted ingroup III 52.0% (n = 78).Schizophrenia60.2% (n = 50) and tumor 42.1% (n = 16) were recorded mostly in the young population belonging to group I. The subjects of group III manifested highly level of Dementia63.5% (n = 33).The proportion of patients suffering from mania was high in group I 44.0% (n = 11) and group II 44.0% (n = 11) respectively (Figure 5). DISCUSSION In developing countries, prevalence and incidence of ND sare underestimated due to lack of data and awareness about the burden and impact. Most of NDs, such as meningitis, encephalitis, and cerebral malaria, the on set of the condition is acute in nature and frequently lethal in a short course of time. Mortality due to many of these NDs could be prevented by early diagnosis and providing effective treatment. Other NDs are chronic in nature, for example epilepsy, and, in addition to the morbidity experienced by the patient, this illness carries a socioeconomic burden and stigmatization is commonly observed in many cases, which also affects the broader family. Timely and accurate diagnosis of such cases may facilitate provision of effective treatment and help prevent the chronicity and post-disease effects on patients and their families . In developing countries, such as Pakistan, diagnosis of complex NDs is challenging due to lack of infrastructure and expertise, which creates a hurdle in determining and providing proper treatment. The present study is the first hospital based study of NDs conducted in Faisalabad, the third largest city of Pakistan. Depression accounted for as substantial portion (19.6%) of the NDs among the study subjects, 11.5% of which were in youth with at least 1 parent who also had depression. This value was close to the global burden (20%), and local burden of depression in Karachi (2023%)– . The higher proportion off depression among the female group(67.1%), as compared to the male group (32.9%), was in accordance with previous studies by various authors . The heritability and burden of ND among the younger generation (10-30 years of age) is reported here for the first time in Pakistan, and highlights an issue of pressing concern. The substantial proportion of NDs among younger generations in Faisalabad suggests that national rates of NDs may be higher than previously assumed and affect more of the population, posing a serious health burden. Epilepsy appeared to be the second most common ND, accounting for 16.6% of cases. One third of cases were found to have a positive family history, and slightly more of the male group (53%) than female group (47%)experienced epilepsy. There was also a higher proportion among patients in the age range of 10-30 years, which is in accordance with previouslyreported data . We also found that of the 15.2% of subjects with a diagnosis of migraine, one third had a positive family history, and the female group (75.4%) accounted for a larger proportion of cases compared to the male group (24.6%). The age groups 10-30 and 30-50 years of age experienced the highest proportion of cases. Age Group 10-30 Age Group 51-70 Age Group 31-50 Age Group 71-90 80.0 tsn60.0 e i ta40.0 p fo20.0 % 0.0 .738 .537 verall O 7 . 0 2 4 7 . 5 .6 4 5 3 0 . 6 1 Our results regarding headache and migraine are not in accordance with other studies conducted elsewhere in Pakistan – . This contradiction of ND burden observed in our results is possibly due to demographic factors, parameters, and the methodology used in those studies. Although specific aspects of our findings differ from previous studies, the trend of NDs in gender and age groups of patients appear similar to data reported previously. The number of patients with PD in Asian countries is expected to reach 6.17 million in a few decades . The presence and increasing burden of PD in some cities of Pakistan has also been documented – , but the nationwide data on prevalence of PD is limited. In the present study, our finding that 3% of the study population has a diagnosis of PD has not been validated in the literature and is higher than the worldwide prevalence of PD of about 1% . A majority of cases in this study was found to demonstrate an inherited pattern of transmission, and the female group experienced a higher proportion of NDs (63%) than the male group (37%).Of concern, the age group 31-50 years were noted to account for a high proportion of cases (38.9%) as compared to other age groups, although NDs are generally a late onset disorder . Schizophrenia affects about 1% of the population and is among the top 25 leading causes of disability worldwide. Its prevalence varies by region and ethnic group .Our study has found that 2.7% of the study population has been diagnosed with schizophrenia, out of which almost 25% have a positive family history. These results cannot be compared with other studies, due to unavailability of existing epidemiological data regarding schizophrenia in Pakistan. Regarding schizophrenia, the burden did not vary significantly by gender and most patients belonged to the 10-30-year age group. The substantial burden of this psychological disorder affecting youth highlights the morbidity experienced in this age group, as well as the expected life-long, future morbidity. Previous studies have reported that birth order, gender difference sand age of on set influence diagnosis and disease trajectory for schizophrenia in Pakistan population – . About 2% of cases were found to be congenital anomalies, and distribution was similar between males and females. Due to varying results from different regions of Pakistan, the present results are in accordance with some studies, 2.9% reported by Khan et. al., 2015 , and contradictory to other results, for example Hussain et. al., 2014 , who reported that about 7% of neonates had congenital anomalies. In UK, researchers have noted that babies born to mothers of Pakistani origin are more prone to be affected with congenital anomalies as compared to babies of mothers from other regions . Various factors such as malnutrition, consanguineous marriages, illiteracy, and unavailability of adequate health care facilities in Pakistan may explain the higher rate of Nds Dementia has increased and is approaching epidemic levels in Pakistan, and requires timely, focused resources. Prevalence of dementia is projected to be much higher in the future – . Dementia accounted for 1.7% of the NDs among study subjects, similar to previous findings of a1.9 % prevalence of dementia in South Asia .The available prevalence data about dementia is limited and prior studies report 8% and 7% of elderly people are suffering from dementia– . Although other disorders,such disc prolapse (8.8%), paralysis (8.5%), trauma (5.3%), brain hemorrhage ( 5 % ) , m a n i a ( 0 . 8 % ) , t u m o r ( 1 . 6 % ) , a c u t e psychological illness (1.4%), disruptive behavior disorder (0.6%), bipolar affective disorder (0.7%) and other miscellaneous minor diseases (6.2%)account for more than one quarter of the NDs among the study population, other studies with which to compare the finding at a national level are unavailable. The presence of major neurological, psychological, and neurodegenerative disorders in Pakistan, the sixth largest population in the world, should not be assumed to be absentnor speculated upon, due to the lack of epidemiological data. Due to an improved health infrastructure and facilitated access to health facilities, life expectancy in Pakistan is increasing, which leads to an increasing population vulnerable to late onset neurodegenerative disorders such as Alzheimer's disease (AD), Huntington's disease (HD), Amyotrophic Lateral Sclerosis (ALS),and PD. These diseases may be prevalent in elderly people of Pakistan, but available data do not exist to describe the epidemiology and describe the population burden. Although the presence of multiple sclerosis (MS) and PD, in Karachi and Peshawar, has been documented at the hospital level. The present study lays a foundation of data regarding ND burden in this region to build a bank of data and address the gap in existing information about this neglected area of disease epidemiology. In the health policy framework of Pakistan, there is little focus on management and treatment of NDs due to lack of data regarding the epidemiology of NDs. It is recommended to conduct community based epidemiological studies in Pakistan. The findings of such studies will pave the way for health policies and fund ingallocation for research, eradication, and improved treatment of NDs in Pakistan. ACKNOWLEDGMENTS We are indebted to Prof. Dr. Imtiaz Ahmad Dogar, Dr. Azam Aslam, Dr. Naeem Ur Rehman, Dr.Muhammad Irfan Ullah, Dr. Khalid Mahmood Yahya, Dr. Faisal Ghafoor, Dr. Irum Farooq, Mr. Muhammad Ilyas and Dr. Amir Sharif for their cooperation and support regarding data collection. We also extend our thanks to Mr. Usama Nadeem and the pioneer batch studentS of the Department of Physiology, GCUF for their help. REFERENCES : 2. Wasay M, Ali S. Growing burden of neurological diseases in Pakistan--need for a national health s u r v e y. J P a k M e d A s s o c [ I n t e r n e t ] 2 0 1 0 ; 6 0 ( 4 ) : 2 4 9 – 5 0 . A v a i l a b l e f r o m : http://www.ncbi.nlm.nih.gov/pubmed/20419960. 3. WHO. Neurological disor P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 0 8 study. BMC Psychiatry [Internet] 2013;13( 1 ):181. Available from: http://www.pubmedcentral.nih. gov/articlerender.fcgi?artid=3704964&tool=pmce ntrez&rendertype=abstract. Author's contribution: Ghulam Hussain; concept, data collection, data analysis, manuscript writing, manuscript review Asif Shehzad; data collection, data analysis, manuscript writing, manuscript review Haseeb Anwar; data analysis, manuscript writing, manuscript review Muhammad Umar Sohaildata analysis, manuscript writing, manuscript review Shahid Mahmood Baig; data analysis, manuscript writing, manuscript review Asghar Shabbir; data analysis, manuscript writing, manuscript review Jose-Luis GONZALEZ DE AGUILAR;manuscript writing, manuscript review Jawed Iqbal; data analysis, manuscript review 1. La Spada A , Ranum LPW . Molecular genetic advances in neurological disease: special review issue . Hum Mol Genet 2010 ; 19 ( R1 ): R1 - 3 . 4. Murray CJL , Vos T , Lozano R , et al. Disabilityadjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990 - 2010 : A systematic analysis for the Global Burden of Disease Study 2010 . Lancet 2012 ; 380 ( 9859 ): 2197 - 223ders : a public health approach . 2006 . 5. Vijayalakshmi R , Hoang-Minh D , Rodolfo G G , et al. Regional research priorities in brain and n e r v o u s s y s t e m d i s o r d e r s . N a t u r e 2015 ; 7578 ( 527 ): 177 - 80 . 6. White ford HA , Degenhardt L , Rehm J , et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010 . Lancet 2013 ; 382 ( 9904 ): 1575 - 86 . 7. Awan S , Shahbaz N , Akhtar SW , et al. Validation Study of the Mini-Mental State Examination in Urdu Language for Pakistani Population . Open Neurol J 2015 ; 9 : 53 - 8 . 8. Borlongan C V. , Burns J , Tajiri N , et al. Epidemiological Survey-Based Formulae to Approximate Incidence and Prevalence of Neurological Disorders in the United States: A Meta-Analysis . PLoS One 2013 ; 8 ( 10 ): 1 -. 9. MacDonald BK , Cockerell OC , Sander JW , Shorvon SD . The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK . Brain 2000 ; 123 ( Pt 4 : 665 - 76 . 10. Gourie-Devi M , Gururaj G , Satishchandra P , Subbakrishna DK . Prevalence of neurological disorders in Bangalore, India: A community-based study with a comparison between urban and rural areas . Neuroepidemiology 2004 ; 23 ( 6 ): 261 - 8 . 11. Gourie-Devi M . Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy, stroke, Parkinson's disease and tremors . Neurol India [Internet] 2014 ; 62 ( 6 ): 588 - 98 . Available from: http://search.ebscohost.com/login.aspx ?direct=tr ue&db=rzh&AN=2012868923&site =ehostlive%5Cnhttp://content.ebscohost.com/ContentS erver.asp?T=P& P= AN&K=100701187 & S=R&D= asm& EbscoContent=dGJyMNLe80Sep7Q4v+bw OLCmr02ep7RSsqy4SLKWxWXS&ContentCust omer=dGJyMPGnsEm2p7. 12. Al Rajeh S , Bademosi O , Ismail H , et al. A community survey of neurological disorders in S a u d i A r a b i a : t h e T h u g b a h s t u d y . Neuroepidemiology 1993 ; 12 ( 3 ): 164 - 78 . 13. Al Salloum AA , El Mouzan MI , Al Omar AA , Al Herbish AS , Qurashi MM . The Prevalence of Neurological Disorders in Saudi Children: A Community-Based Study . J Child Neurol [Internet] 2 0 1 1 ; 2 6 ( 1 ) : 2 1 - 4 . A v a i l a b l e f r o m : http://jcn .sagepub.com/cgi/doi/10.1177/0883073 810371510. 14. Wasay M. Neurological Care in Pakistan: Actions are needed . J Pak MedAssoc 2003 ; 53 ( 12 ): 576 . 15. Mehndiratta MM , Khan M , Mehndiratta P , Wasay M. Stroke in Asia: geographical variations and temporal trends . J Neurol Neurosurg Psychiatry [ I n t e r n e t ] 2 0 1 4 ; 1 - 6 . A v a i l a b l e f r o m : http://www .ncbi.nlm.nih.gov/pubmed/24769474. 16. Winkler AS , Mosser P , Schmutzhard E . Neurological disorders in rural Africa: a systematic approach . Trop Doct 2009 ; 39 ( 2 ): 102 - 4 . 17. Taqui AM , Itrat A , Qidwai W , Qadri Z. Depression in the elderly: does family system play a role? A cross-sectional study . BMC Psychiatry 2007 ; 7 : 57 18. Ganatra HA , Zafar SN , Qidwai W , Rozi S. Prevalence and predictors of depression among an elderly population of Pakistan . Aging Ment Health [Internet] 2008 ; 12 ( 3 ): 349 - 56 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/ 18728948. 19. Bhamani MA , Karim MS , Khan MM . Depression in the elderly in Karachi, Pakistan: a cross sectional 20. Mumford DB , Saeed K , Ahmad I , Latif S , Mubbashar MH . Stress and psychiatric disorder in rural Punjab. A community survey . Br J Psychiatry 1997 ; 170 : 473 - 8 . 21. Mumford DB , Minhas FA , Akhtar I , Akhter S , Mubbashar MH . Stress and psychiatric disorder in urban Rawalpindi: Community survey . Br J Psychiatry 2000 ; 177(DEC .): 557 - 62 . 22. Khatri IA , Iannaccone ST , Ilyas MS , Abdullah M , Saleem S. Epidemiology of Epilepsy in Pakistan: Review of literature . J Pak Med Assoc 2003 ; 53 ( 12 ): 594 - 7 . 23. Aziz H , Güvener A , Akhtar SW , Hasan KZ . Comparative epidemiology of epilepsy in Pakistan and Turkey: Population- based studies using identical protocols . Epilepsia 1997 ; 38 ( 6 ): 716 - 22 . 24. Murtaza M , Kisat M , Daniel H , Sonawalla AB . Classification and clinical features of headache disorders in Pakistan: A retrospective review of clinical data . PLoS One 2009 ; 4 ( 6 ): 1 - 8 . 25. Khan A , Khattak H , Jamali R , Rashid H , Riaz A , Ibrahimzai AK . Prevalence of Migraine , Its Common Triggering Factors and Coping Strategies in Medical OF PESHAWAR . Khyber Med Univ J 2012 ; 4 ( 4 ): 187 - 92 . 26. Kafeel H , Rukh R . Prevalence of headache in general population of Karachi, Pakistan. J Appl Pharm 2014 ; 6 ( 3 ): 308 - 13 . 27. Zahid M , Sthanadar AA , Kaleem M , et al. Prevalence and Perceptions about Migraine among Students and Patients in Khyber Pakhtunkhwa Province, Pakistan . Adv Biosci Biotechnol [Internet] 2014 ; 5 ( 6 ): 508 - 16 . Available f r o m h t t p : / / w w w . s c i r p . o r g / j o u r n a l / PaperInformationaspx?PaperID= 45735 &# abstract. 28. Tan LCS . Epidemiology of Parkinson ' s disease . NeurolAsia 2013 ; 18 ( 3 ): 231 - 8 29. Asumal B , Khealani , Shahid Mustafa B. Clinical spectrum of Parkinson's disease from Pakistan . Singapore Med J 2006 ; 47 ( 12 ): 1075 - 9 30. Hussain T , Amjad A , Khan F. Incidence , Prevalence And Clinical Pathway Of Parkinson's Disease Among Pakistani Population . Mov Disord [Internet] 2013 ; 28 : S471 -- S479 . Available from: http://dx.doi.org/10.1002/mds.25609. 31. Adnan Y , Sarwar Jamil S , Iqbal A , Mohammad W. Vitamin D deficiency in Parkinsons disease patients at a tertiary care centre in Karachi, Pakistan . Pakistan J Neurol Sci 2012 ; 7 ( 2 ): 9 - 11 . 32. Yakunin E , Loeb V , Kisos H , et al. Α-synuclein neuropathology is controlled by nuclear hormone receptors and enhanced by docosahexaenoic acid in a mouse model for Parkinson's disease. Brain P a t h o l [ I n t e r n e t ] 2 0 1 2 [ c i t e d 2 0 1 3 A p r 1 0 ] ; 2 2 ( 3 ) : 2 8 0 - 9 4 . A v a i l a b l e f r o m : http://www .ncbi.nlm.nih.gov/pubmed/21929559. 33. Rahman SU , Ilahi I , Khan S , Khan AA , Khan MZ . Parkinson's disease; Its Occurrence and Identification of Risk Factors in Khyber Pakhtunkhwa, Pakistan . J Biol Life Sci [Internet] 2 0 1 2 ; 4 ( 1 ) : 1 7 2 - 8 0 . A v a i l a b l e f r o m : http://www .macrothink.org/journal/index.php/jbls/ article/view/2625. 34. Ahmed W , Razaq A , Khan RA , Ahmad M , Shah F. Parkinson's Disease : A Review of Its Prevalence, Risk Factors and Latest Human's Embryonic Stem Cell Technique for its Treatment . Ann Pakistan Inst Med Sci 2014 ; 10 ( 4 ): 166 - 71 . 35. Millier A , Schmidt U , Angermeyer MC , et al. Humanistic burden in schizophrenia: A literature review . J Psychiatr Res [Internet] 2014 ; 54 ( 1 ): 85 - 93 . Available from: http://dx.doi.org /10.1016/j.jpsychires. 2014 . 03 .021. 36. Chong HY , Teoh SL , Wu DB -C, Kotirum S , Chiou CF , Chaiyakunapruk N. Global economic burden of schizophrenia: a systematic review . Neuropsychiatr Dis Treat [Internet] 2016 ; 12 : 357 - 73 . Available from: http://www.pubmedcentral.nih.gov/articlerender.fcg i?artid=4762470& tool=pmcentrez&rendertype=ab stract . 37. Stompe T , Ortwein-Swoboda G , Friedmann A , Chaudhry HR . Sibling orders of schizophrenia patients in Austria and Pakistan . Psychopathology [Internet] 1999 ; 32 ( 6 ): 281 - 91 . Available from: http://ezproxy.msu.edu/login?url=http://search.pro quest.com/docview/619435440?accountid= 12598 %5Cnhttp://magic.msu.edu:4550/resserv?genre= a rticle&issn=02544962&title=Psychopathology&vol u m e = 3 2 & i s s u e = 6 & d a t e = 1 9 9 9 - 1 1 - 01 &atitle=Sibling+orders+of+schizophrenia+pat. 38. Bender KG . Birth Order and Schizophrenia in A u s t r i a a n d P a k i s t a n . P s y c h o p a t h o l o g y 2001 ; 34 : 109 - 10 . 39. Ansari MA , Rahman R , Siddiqui AA , Zaidi SZH . Association of Order of Birth with Schizophrenia . Pakistani J Med Sci 2010 ; 26 ( 1 ): 49 - 53 . 40. Naqvi I , Murtaza M , Nazir MR , Naqvi HA . Gender difference in age at onset of schizophrenia: a cross sectional study from Pakistan . J Pak Med Assoc 2010 ; 60 ( 10 ): 886 - 9 . 41. Khan A , Zuhaid M , Fayaz M , et al. Frequency of Congenital Anomalies in Newborns and Its Relation to Maternal Health in a Tertiary Care Hospital in Peshawar, Pakistan [Internet] . Int. J. Med . Students. 2015 ; 3 ( 1 ): 19 - 23 . Available from: http://www.ijms.info/ojs/index.php/IJMS/article/vie w/231/v3i1a5.html. 42. Hussain S , Asghar I , Sabir M ud D , Chattha MN , Tarar SH , Mushtaq R . Prevalence and pattern of congenital malformations among neonates in the neonatal unit of a teaching hospital . J Pak Med Assoc 2014 ; 64 ( 6 ): 629 - 34 . 43. Sheridan E , Wright J , Small N , et al. Risk factors for congenital anomaly in a multiethnic birth cohort: An analysis of the Born in Bradford study . Lancet [Internet] 2013 ; 382 ( 9901 ): 1350 - 9 . Available from: http://dx.doi.org/10.1016/S0140- 6736 ( 13 ) 61132 - 0 . 44. Jabeen N , Malik S. Prevalence of congenital anomalies and non-communicable diseases in women of age 12-75 years in District Bhimber, Azad Jammu and Kashmir, Pakistan. Iran J Public Health 2014 ; 43 ( 1 ): 42 - 9 . 45. Raza M.Z. , Sheikh A. , Ahmed S.S. , Ali S. NSMA , Raza MZ , Sheikh A , et al. Risk factors associated with birth defects at a tertiary care center in Pakistan . Ital J Pediatr 2012 ; 38 ( 68 ): 1 - 7 46. Ahmad A , Owais K , Siddiqui M , Mamun K , Rao F , Yousufzai W. Dementia in Pakistan  : National Guidelines for Clinicialn . Pakistan J Neurol Sci 2013 ; 8 ( 3 ): 17 - 27 47. Khatri IA , Wasay M. DEMENTIA – THE NEXT IMPENDING EPIDEMIC KNOCKING ON OUR DOOR – ARE WE READY ? Pakistan J Neurol Sci 2013 ; 8 ( 3 ): 2 - 3 . 48. Anonymous . Number of people with dementia g r o w i n g i n P a k i s t a n , s a y e x p e r t s . T h e News.com .pk. 2015 . 49. Kalaria RN , Maestre GE , Arizaga Raul , et al. Alzheimer's disease and vascular dementia in developing countries: prevalence, management, and risk factors . Lancet Neurol 2008 ; 7 ( 9 ): 812 - 26 . 50. Hoori S , Syed Wasim A , Shaukat A. Clinical spectrum of multiple sclerosis at a tertiary care hospital in Pakistan . Pakistan J Med Sci 2008 ; 24 ( 2 ): 221 - 6 . Funding disclosure: The study was supported by Higher Education Commission of Pakistan under the grant Number : 21 - 391 SRGP /R&D/HEC/2015


This is a preview of a remote PDF: https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1194&context=pjns

Ghulam Hussain, Asif Shahzad, Haseeb Anwar, Shahid Mahmood Baig, Asghar Shabbir, Jose-luis Gonzalez De Aaguilar. Neurological disorder burden in Faisalabad, Punjab-Pakistan:data from the major tertiary carecenters of the city, Pakistan Journal of Neurological Sciences (PJNS), 2017,