Socio-demographic characteristics of children and young people with primary brain tumours: comparison between a public and private sector tertiary hospital in Karachi, Pakistan.

Primary brain tumours (PBTs) are the commonest solid tumours in children and young people (CYP). A study was conducted at a private and a public sector hospital in Karachi, Pakistan, to determine the socio-demographic and tumour-related characteristics of CYP with PBTs between those presenting to the public and private hospitals. A total of 49 patients were included. The commonest PBT was pilocytic astrocytoma (29%). There were no differences in tumour-related characteristics between the two groups. However, parents of CYP with PBTs presenting to the public sector hospital were significantly less educated and had lower household incomes. No significant differences in age, gender, educational status, and ethnicity of CYP with PBTs were observed. Since CYP with PBTs presenting at the public sector hospital were from significantly lower socioeconomic backgrounds and their parents were less educated, it suggests socio-economic disparities in PBT care for CYPs in Karachi, Pakistan.

Pakistan National Guidelines for Pediatric High-Grade Gliomas.

Pediatric high-grade glioma (pHGG) is highly malignant central nervous system tumor and constitute 10% of the pediatric gliomas. Effective treatment needs a functioning multi-disciplinary team including pediatric neuro oncologist, neurosurgeon, neuroradiologist, neuropathologist and radiation oncologist. Despite surgical resection, radiotherapy and chemotherapy, most HGG will recur resulting in early death. A significant proportion of HGG occurs in context of cancer predisposition syndromes like Constitutional Mismatch Repair Deficiency (CMMRD) also known as Biallelic Mismatch Repair Deficiency (bMMRD) characterized by high mutational burden. The incidence of HGG with CMMRD is one per million patients. bMMRD is caused by homozygous germline mutations in one of the four Mis Match Repair (MMR) genes (PMS2, MLH1, MSH2, and MSH6). The use of TMZ is now avoided in CMMRD related HGG due to its limited response and known ability to increase the accumulation of somatic mutations in these patients, increasing the risk of secondary tumors. HGG should be managed under the care of multidisciplinary team to receive optimum treatment. This is particularly important for low middle-income countries (LMIC) with limited resources like Pakistan.

Cultural Barriers for Women in Surgery: How Thick is the Glass Ceiling? An Analysis from a Low Middle-Income Country.

BACKGROUND: This study aimed to highlight cultural barriers faced by surgeons pursuing a surgical career faced by surgeons at a tertiary care hospital in Pakistan. As more females opt for a surgical career, barriers faced by female surgeons are becoming increasingly evident, many of which are rooted in cultural norms. In Pakistan, a predominantly Muslim-majority, low middle-income country, certain societal expectations add additionally complexity and challenges to existing cultural barriers. METHODS: A cross-sectional survey was administered via e-mail to the full-time faculty and trainees in the Department of Surgery at the Aga Khan University Hospital, Karachi, Pakistan, from July 2019 to November 2019. RESULTS: In total, 100 participants were included in this study, with the majority being residents (55.6%) and consultants (33.3%). 71.9% of female surgeons felt that cultural barriers towards a surgical career existed for their gender, as compared to 25.4% of male surgeons (p < 0.001). 40.6% of females reported having been discouraged by family/close friends from pursuing surgery, as compared to only 9.0% of males (p < 0.001). Moreover, a greater percentage of females surgeons were responsible for household cooking, cleaning and laundry, as compared to male surgeons (all p < 0.001). Lastly, 71.4% of female surgeons felt that having children had hindered their surgical career, as compared to 4.8% of males (p < 0001). CONCLUSION: Our study shows that significant cultural barriers exist for females pursuing a surgical career in our setting. Findings such as these emphasize the need for policy makers to work towards overcoming cultural barriers.

Are Rural Hospitals in Pakistan Responding to the Global Surgery Movement? An Analysis of the Gaps, Challenges and Opportunities.

BACKGROUND: Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan. METHODS: This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool. RESULTS: This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population. CONCLUSIONS: Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention.

Anaesthetic Management of Cerebral Arterio-venous Malformation Excision Using Awake Craniotomy: Initial Experience of Two Cases.

This case series summarises the successful management of two cases with cerebral arterio-venous malformation (AVM). In first patient, it was located superficially in right frontal cortex, while the second one had this in left parieto-temporal region. Both were excised successfully using awake craniotomy. The patients had their assessment and psychological preparation by neuro-anesthetist and neurosurgeon. Along with the routine monitoring, invasive arterial line, and bispectral index monitoring was used to monitor the sedative effect of propofol. Intraoperative analgesia was provided using scalp block. The anaesthetic management was helpful in facilitating intraoperative neurological monitoring using verbal and motor responses. Patients remained pain-free and hemodynamically stable during resection phase. The postoperative period showed adequate pain control, decreased postoperative nausea/vomiting and shorter length of stay in the hospital. Both patients had 100% obliteration of AVM confirmed via cerebral angiography.

Resilience and quality of life (QoL) of head and neck cancer and brain tumour survivors in Pakistan: an analytical cross-sectional study protocol.

BACKGROUND: Cancer is a devastating disease and has detrimental effects on the quality of life (QoL) of cancer survivors and interferes with their treatment compliance. The aim of the study is to assess resilience and QoL among cancer survivors and to evaluate the important factors affecting their resilience and QoL, with respect to the Pakistani cultural context. METHOD AND ANALYSIS: A cross-sectional study will be conducted at a tertiary care hospital in Karachi, Pakistan. A minimum sample size of 250 head and neck cancers and 250 brain tumour survivors with 10% inflation for non-response rate will be required. The SD of QoL and resilience will range from 16.5 to 40.8 for head and neck cancer, and 12.7 to 34.1 for brain tumour, at 5% level of significance, with 2.5 precision. QoL will be assessed by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-H&N35 and EORTC QLQ-BN20 and resilience will be evaluated by Wagnild and Young's 14-item scale. Mean±SD will be reported for resilience and QoL scores. Unadjusted and adjusted ß-coefficients, with 95% CI, will be reported by using multiple linear regression analysis. Correlation analysis will also be performed using Pearson or Spearman rank correlation coefficients. A p value of <0.05 will be considered significant. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Aga Khan University Pakistan's Ethical Review Committee. Written informed consent will be taken from the participants by trained research assistants. A trained psychologist will provide on-spot counselling to the participants and those identified with severe depression will be referred to a psychiatrist. The study materials will be kept under lock and key and the electronic data base will be password protected and will only be accessed by the research team. The study findings will be disseminated through publications conferences and workshops and research briefs. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov registry (NCT03466762).

An Awake Throughout Approach for Awake Craniotomy: A Perspective from a Resource-Limited Country.

BACKGROUND: An awake throughout (AT) approach for awake craniotomy is mostly under utilized. The purpose of this study was to review the efficacy of the technique at our tertiary care center. The primary objective was to identify the incidence of perioperative complications. The secondary objective was to review the patients' satisfaction, satisfaction of surgical team, length of stay (LOS) in special care unit (SCU), and overall LOS in the hospital. METHODS: The study was a retrospective review of patients data. All patients were treated with the AT technique. This included preoperative assessment, psychologic preparation, and institution of scalp block. The incidence of perioperative complications, including satisfaction of surgical team was noted. The patients' satisfaction and the LOS in SCU and in the hospital was also recorded. RESULTS: In total, the data from 55 patients were reviewed. Their mean age was 41 years, and 63% were reported to have seizures at presentation. The AT approach was successful in 100% of cases. The incidence of intraoperative seizures was 7.4%, of vomiting was 5.4%, and of conversion to general anesthesia was 0%. The surgical team was able to perform gross total resection in 53% of patients and rated a satisfaction score of 8 out of 10. Postoperative seizures occurred in 5.4% of patients and vomiting in 3.6%. The mean LOS in SCU was 1.2 days, and the overall hospital LOS was 4 days. The patients remained fully satisfied, as evidenced by a mean satisfaction score of 8.6. CONCLUSION: An AT approach might be very useful in resource-limited setups because of the low incidence of complications, the use of resources, and significant surgeon and patient satisfaction.

Anaesthetic Management of Supratentorial Tumor Craniotomy Using Awake-Throughout Approach.

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length of stay in hospital.

Magnetic resonance spectroscopy of enhancing cerebral lesions: analysis of 78 histopathology proven cases.

OBJECTIVES: To investigate the efficacy of magnetic resonance spectroscopy in differentiating various types of neoplastic and non-neoplastic enhancing cerebral lesions. METHODS: The prospective study was conducted from January 2007 to December 2009 at the Department of Radiology, Aga Khan University Hospital, Karachi. All patients with enhancing brain lesions on magnetic resonance imaging who underwent magnetic resonance spectroscopy and a biopsy with histopathological analysis were included in study. The lesions were categorised into neoplastic and non-neoplastic lesions on the basis of spectroscopy findings. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of magnetic resonance spectroscopy were calculated. Predicted probabilities were computed and comparison of median values of metabolites and their ratios was analysed using non-parametric Mann Whitney U test to differentiate between neoplastic and non-neoplastic lesions. RESULTS: Of the 102 patients enrolled, 78 (76.5%) comprised the final study sample. There were 53 (68%) male and 25 (32%) female patients with an overall mean age of 40.21 ± 17.69 years (range: 4-76 years). The mean overall size of the lesion was 4.01 ± 1.79 cm, and 61(78%) lesions were neoplastic and 17 (22%) were non-neoplastic. The sensitivity, specificity, positive predictive value and negative predictive value and diagnostic accuracy of magnetic resonance spectroscopy in differentiating neoplastic and non-neoplastic lesions were 90.16%, 64.70%, 90.16%, 64.70% and 78.20% respectively. A cut-off value of 2.55 of Choline/N-Acetyl Aspartate ratio depicted sensitivity of 70% in differentiating the lesions. CONCLUSION: Magnetic resonance spectroscopy is a highly sensitive technique in addition to conventional magnetic resonance imaging in characterising and differentiating between neoplastic and non-neoplastic cerebral lesions.

Role of irrigation with hypertonic saline for a recurrent skull base hydatid cyst: case report and review of the literature.

Hydatid cyst is a parasitic disease caused by the tapeworm Echinococcus granulosus. This disease is a rare finding in the head and neck region, and its presentation varies according to the area involved. We report the case of a 25-year-old woman who presented with bilateral neck swelling, which was found on histopathologic examination to be caused by a hydatid cyst. The patient underwent surgical drainage of the cyst and a modified radical mastoidectomy, followed by a 3-month course of treatment with albendazole. However, she experienced a recurrence in the left neck region 1 year later. At that time, reexploration of the left mastoid cavity was performed, with debridement of diseased occipital bone and foramen magnum. Intraoperatively, we used a novel method of saline irrigation with 3% hypertonic saline, previously not tested on exposed nerves, in an attempt to prevent further recurrence. Four years after the second surgery, no disease recurrence was found, and no neurologic sequelae were noted. We conclude that hypertonic saline irrigation can be considered as an option for preventing recurrence in cases that are difficult to clear surgically, especially around cranial nerves, although more studies are needed to document the safety of this approach.