Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S.

Introduction: Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant. Methods: We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints. Results: A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three. Discussion: The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

Prognostic impact of pre-referral tumor resection in unilateral Wilms tumor: A single-institute experience from a lower middle-income country.

INTRODUCTION: The objectives of this study were to evaluate the prognostic impact of pre-referral surgical resection of Wilms tumor (WT) performed at non-oncology centers, and to strategize an improved care plan for this very curable pediatric tumor. METHODS: In this study conducted in a large pediatric cancer center in Pakistan, we retrospectively reviewed the electronic medical records (EMR) of 149 patients with unilateral WT from September 2008 to August 2017. Based on treatment approach, patients were categorized into two groups: (i) pre-referral tumor resection (PTR: n = 75), and (ii) post-neoadjuvant chemo nephrectomy (PCN: n = 74). RESULTS: The proportion of metastatic disease in PTR and PCN groups was 33.3% and 35.1%, respectively. In the PTR subset, median time to admission after PTR was 5 weeks (mean 11, SEM 2.8, range: 2-202) weeks, with 53.3% (n = 40) presenting more than 4 weeks after PTR. Twenty patients had no cross-sectional imaging prior to PTR and underwent surgery after abdominal ultrasound only. On baseline imaging at our center, 58.7% (n = 44) of the PTR group had radiologically evaluable disease (four metastases only, 19 local residual tumor only, 21 both localized tumor and visible metastases). Disease staging was uncertain in 23 patients because of no or inadequate histology specimens and/or lymph node sampling in patients with no evaluable disease. Statistically significant differences were recorded for the two subsets regarding tumor volume, extent and nodularity, renal vein and renal sinus involvement, lymph node status, tumor rupture and histopathologic features, and tumor stage, with a 10-year event-free survival (EFS) for PCN and PTR of 74.3% and 50.7%, respectively (p < .001). In the PTR group, EFS for those presenting within 4 weeks and later was 91.4% versus 15.0%, respectively (p < .0001). CONCLUSION: Suboptimal pre-referral surgical intervention results in poor survival outcomes in unilateral WT. Our findings highlight the need for a comprehensive action plan for educating healthcare professionals engaged in WT diagnosis and referral process. PCN in a multidisciplinary team approach can reduce surgical morbidity and seems to be a better strategy to improve the survival rates in low-resource settings.

Etiology of Acute Infectious Meningitis and Meningoencephalitis in Karachi, Pakistan: Retrospective Observational Study from a Tertiary Care Center.

Meningoencephalitis (ME) is potentially fatal and is caused by a wide array of pathogens. Diagnostic and health-care access gaps prevent accurate estimation of the pathogen-specific burden in low-resource settings. We present pathogen-specific etiologies among patients hospitalized with ME in Karachi, Pakistan. We performed a retrospective hospital database evaluation of pathogen etiology and outcomes of community-acquired infectious ME at a single tertiary care center in Karachi, Pakistan. Annual rates of hospitalization (ARH) were calculated by adjusting for missed cases and are reported per 100,000 population. From May 2017 to April 2020, 522 episodes of infectious ME were identified in 514 patients. The overall ARH from ME was 5.7/100,000 population (95% CI, 5.1-6.1). Among children younger than 5 years, the ARH was 9.8/100,000 population (95% CI, 8.1-11.8). Unknown causes of ME resulted in the greatest burden, with an ARH of 1.9/100,000 population (95% CI, 1.7-2.2). Among known causes, the greatest burden of hospitalizations resulted from tuberculous ME (0.8/100,000; 95% CI, 0.6-0.97), followed by pneumococcal and enteroviral ME (both 0.6/100,000 population; 95% CI, 0.5-0.8). The burden of ME caused by pathogens preventable through vaccination or public health measures outweighed that of ME from other causes (P = 0.0092, Fisher's exact test). We report a broad range of pathogens causing ME in southern Pakistan and show a high burden of preventable illness. Synergistic actions to improve diagnostic strategies, increase vaccinations, and introduce measures to reduce water-borne and vector-borne diseases are required to reduce the ME burden in Pakistan and prevent future outbreaks.

Tumour lysis syndrome as a rare complication of chemotherapy in paediatric Wilms' Tumour: a case report.

Wilms tumour is the most common renal malignancy in children, with two-thirds of cases diagnosed before five years and 95 percent before 10 years of age. Over the last decade, the five-year survival rate has improved dramatically and now approaches 90 %. Tumour lysis syndrome, commonly seen in association with haematological malignancies, is rarely seen in Wilms tumour. We present two cases of Wilms tumour developing tumour lysis syndrome in the first week of initiation of chemotherapy. Both patients presented with huge abdominal masses causing mass effect on surrounding structures. Chemotherapy was administered as per International Society of Pediatric Oncology guidelines (SIOP). Both patients developed laboratory and clinical tumour lysis syndrome (TLS) after the first cycle of chemotherapy requiring continuous renal replacement therapy (CRRT). However, both died because of multiorgan failure.

Fungal isolation from wound samples submitted for culture at a tertiary care hospital laboratory.

Fungal wound infections are increasing worldwide. The aim of this retrospective study, conducted at the Aga Khan University laboratory, Karachi, Pakistan, was to determine the frequency of fungal isolation in wound specimens. Data of wound samples received for culture from all over the country between September and October 2018 was reviewed. Samples were processed for bacterial cultures and additionally inoculated on Sabouraud's dextrose medium. Demographic information, medical history and information on the type of wound was collected. A total of 140 cases were included, of which 87 (81%) were culture positive, while 10 (7%) cases yielded fungi. Burn and blast wounds had the highest proportion of fungal isolation, i.e. 2 out of 4 (50%). Candida species were the most common fungi (n=4), followed by Fusarium species (n=3). This study reports an alarming rate of fungal wound infections. As fungal necrotising wound infections have high morbidity and mortality, it is, therefore, important to accurately diagnose and treat such infections in local setting.

Survival outcomes of unilateral retinoblastoma based on pathological risk stratification-experience at a tertiary care centre in Pakistan.

Retinoblastoma (RB) is the most common childhood intraocular malignancy. In high-income countries over the past decade, upfront enucleation for unilateral RB is least favoured due to other alternatives that can help in globe preservation, but in low-middle income countries it is still the preferred option due to lack of resources and expertise. The treatment of RB after enucleation is tailored based on the histopathological risk features, as adjuvant chemotherapy with high-risk features reduces the risk of metastasis. The aim of our study was to analyse the survival outcomes of adjuvant therapy based on histopathological risk stratification in patients who underwent upfront enucleation for unilateral RB with advanced disease. A retrospective study was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan. A total 113 patients (aged 3 months till 16 years) diagnosed with unilateral RB who had upfront enucleation from July 2009 till January 2019 were included in this study. The mean age of diagnosis was 37.4 months (±24.5) and male-to-female ratio of 1.3:1. The most common clinical presentation was leukocoria (74.3%). Patients who underwent enucleation had advanced disease; group D present in 62.8% followed by group E (32.7%). Histopathology revealed high-risk features in 29 patients (25.7%) and intermediate risk in 54 patients (47.8%). Disease progression and relapse was seen in patients with high-risk histopathological features. The 4-year over-all survival and EFS observed for this cohort was 74% and 71%. Awareness about the early symptoms among the general population and health care personnel at a nationwide level is needed to facilitate early detection and lessen disease related morbidity and mortality.

Mechanistic study of regulation of iron homeostasis by N. sativa seeds and P. ovata husks on high fat/high sucrose diet induced non-alcoholic fatty liver disease.

BACKGROUND: In recent years, nonalcoholic fatty liver disease (NAFLD) has reached epidemic proportions. Characteristic findings in NAFLD patients are elevated iron stores, as iron plays an important role in the pathophysiology of chronic liver disease. The current study was aimed at investigating the possible protective effects of N. sativa seeds and P. ovata husks on the regulation of iron homeostasis in NAFLD. METHODS: Two age groups of Wistar rats (four weeks and twelve weeks old), further subdivided into four groups were fed on high fat/high sucrose (HF/SF) diet for sixteen weeks to induce NAFLD and randomized into three groups (HF/SF diet control (Group I), HF/SF diet with N. sativa seeds (Group II) and HF/SF diet with P. ovata husks (Group III) and normal diet, serving as negative control (Group 0). At the end of the experiment, histochemical analysis of hepatic sections, biochemical evaluates of the blood, and gene expression analysis were conducted. RESULTS: The results revealed that both N. sativa seeds and P. ovata husks possess the capacity to maintain iron homeostasis by regulating the level of blood hemoglobin, serum iron contents, expression of key genes involved in iron metabolism, and iron deposition in hepatic sections. While N. sativa seeds proved more effective. CONCLUSIONS: N. sativa seeds are a more potent iron regulator compared to P. ovata husks at reducing the iron overburden associated with NAFLD.

Building the ecosystem for pediatric neuro-oncology care in Pakistan: Results of a 7-year long twinning program between Canada and Pakistan.

BACKGROUND: Low- and middle-income countries sustain the majority of pediatric cancer burden, with significantly poorer survival rates compared to high-income countries. Collaboration between institutions in low- and middle-income countries and high-income countries is one of the ways to improve cancer outcomes. METHODS: Patient characteristics and effects of a pediatric neuro-oncology twinning program between the Hospital for Sick Children in Toronto, Canada and several hospitals in Karachi, Pakistan over 7 years are described in this article. RESULTS: A total of 460 patients were included in the study. The most common primary central nervous system tumors were low-grade gliomas (26.7%), followed by medulloblastomas (18%), high-grade gliomas (15%), ependymomas (11%), and craniopharyngiomas (11.7%). Changes to the proposed management plans were made in consultation with expert physicians from the Hospital for Sick Children in Toronto, Canada. On average, 24% of the discussed cases required a change in the original management plan over the course of the twinning program. However, a decreasing trend in change in management plans was observed, from 36% during the first 3.5 years to 16% in the last 3 years. This program also led to the launch of a national pediatric neuro-oncology telemedicine program in Pakistan. CONCLUSIONS: Multidisciplinary and collaborative efforts by experts from across the world have aided in the correct diagnosis and treatment of children with brain tumors and helped establish local treatment protocols. This experience may be a model for other low- and middle-income countries that are planning on creating similar programs.

Ring-shaped cataract and urinary metabolites among 2,4,6-trinitrotoluene exposed population of Pakistan.

BACKGROUND: Safety protocols are usually neglected among most of the trinitrotoluene (TNT)-exposed population, therefore, rendering the community prone to various occupational hazards. The current study highlights ring-shaped cataract and urinary metabolites of TNT among TNT-exposed population (n = 26) against a control group (n = 20). METHOD: An observational case-control study was carried out in two groups: subjects exposed to TNT in Dir and Bajour Agency, Pakistan, and a control group from the base hospital. We determined the presence of ring-shaped cataract and urine metabolites of TNT using slit-lamp biomicroscope and gas chromatography-mass spectrometric analysis, respectively. RESULTS: Results substantiate a high level of urine metabolites for exposed subjects compared to the control group (p < 0.001). Age had no significant effect (p > 0.05) on the presence of ring-shaped cataract and the level of urinary metabolites of TNT, while duration of exposure showed significant effect (p < 0.001). Females showed high incidence of ring-shaped cataract and urinary metabolites of TNT than men ( p < 0.001). The mean age of the exposed subjects was 51 ± 14.38 (Mean ± SD) years. The mean year of exposure was 49 ± 5 (Mean ± SD) years. CONCLUSION: This study showed TNT as a risk factor for the presence of ring-shaped cataract among TNT-exposed group in Pakistan. It is important to screen exposed community for the presence of ring-shaped cataract, and pre-clinical identification of TNT adducts to prevent systemic complications.

Outcome of Postchemotherapy Residual Disease in Extracranial Germ Cell Tumor in Children: Experience of a Tertiary Care Center.

OBJECTIVES: The aim was to review outcome with residual disease at the end of first line chemotherapy in patients with extracranial germ cell tumor (GCT) in our resource limited setting. METHODS: A retrospective analysis of 196 patients with GCT recruited at Shaukat Khanum Memorial Cancer Hospital (SKMCH) from January 2008 to December 2016. Data fields included site, histopathology, stage, risk groups, baseline alpha fetoprotein, beta human chorionic gonadotropin levels, residuum after primary treatment, completeness of surgical excision and outcomes. Data analysis involved quantitative analysis, mean and median calculations, event free survival (EFS) and overall survival (OS) calculations using Kaplan-Meier curves. RESULTS: In 196 included patients, M:F ratio was 1. There were 81 (41.3%) adolescents. Alpha fetoprotein was >10,000 IU/L in 56 (28.6%) patients. Sixty-two (31.6%) patients had extragonadal disease. Most patients (n=137, 69.9%) presented with advanced stage (III/IV). Seventy-six patients had postchemotherapy residual disease (n=59 [78%] with partial response (PR) and 17 [22%] with no response [NR]). Five-year OS was 83% and EFS was 67%. Five-year EFS of patients with complete remission after primary chemotherapy was 85% versus 70% in patients with PR and 6% in those with NR (P=0.001). OS in patients with complete remission, PR and NR was 94%, 87%, and 46%, respectively. All patients with NR progressed or relapsed and 8/17 died. Four patients with normalized tumor marker response were found to have active tumor on resection of postchemotherapy residuum. CONCLUSION: Patients with postchemotherapy residual disease in pediatric extracranial GCTs, fare better if their residuum is resected compared with those who do not undergo resection.

Polycomb Requires Chaperonin Containing TCP-1 Subunit 7 for Maintaining Gene Silencing in Drosophila.

In metazoans, heritable states of cell type-specific gene expression patterns linked with specialization of various cell types constitute transcriptional cellular memory. Evolutionarily conserved Polycomb group (PcG) and trithorax group (trxG) proteins contribute to the transcriptional cellular memory by maintaining heritable patterns of repressed and active expression states, respectively. Although chromatin structure and modifications appear to play a fundamental role in maintenance of repression by PcG, the precise targeting mechanism and the specificity factors that bind PcG complexes to defined regions in chromosomes remain elusive. Here, we report a serendipitous discovery that uncovers an interplay between Polycomb (Pc) and chaperonin containing T-complex protein 1 (TCP-1) subunit 7 (CCT7) of TCP-1 ring complex (TRiC) chaperonin in Drosophila. CCT7 interacts with Pc at chromatin to maintain repressed states of homeotic and non-homeotic targets of PcG, which supports a strong genetic interaction observed between Pc and CCT7 mutants. Depletion of CCT7 results in dissociation of Pc from chromatin and redistribution of an abundant amount of Pc in cytoplasm. We propose that CCT7 is an important modulator of Pc, which helps Pc recruitment at chromatin, and compromising CCT7 can directly influence an evolutionary conserved epigenetic network that supervises the appropriate cellular identities during development and homeostasis of an organism.

Impact of COVID-19 Pandemic on Treatment of Pediatric Oncology Patients: Report from Resource-limited Setting.

The aim of this study was to determine how the COVID-19 pandemic impacted on the effective management; and the outcome of pediatric oncology patients in Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore. Data was retrospectively reviewed from 15 March to 15 June 2020 after the approval of Institutional Review Board Committee. A total of 258 patients on active oncology treatment between the study period were included. The total number of patients whose treatment was affected were 118 (45.7%), while 140 (54.3%) patients received treatment in time. There was total 34 (13.2%) patients relapsed, 23 (67.6%) patients in which treatment delayed, and 11 (32.4%) patients in which their treatment not delayed; while, n=218 (84.5%) were in remission, and 6 (2.3%) patients absconded. COVID-19 pandemic caused a sudden impediment in the treatment of pediatric oncology patients, and is likely to affect the long-term survival outcome of pediatric oncology patients. Key Words: Chemotherapy, Radiotherapy, Surgery, Long term outcome.

Acute Morbidity and Mortality Analysis of COVID-19 in Children Receiving Cancer Treatment.

The aim of this study was to determine overall morbidity and mortality of COVID-19 infection in children on cancer treatment. It was an observational study, carried at Shaukat Khanum Cancer Hospital from 1st April 2020 to 31st July 2020. A total of 165 children on active cancer treatment were tested for COVID-19 with PCR; out of these, 17 were detected positive. Twelve children were symptomatic having fever with or without cough, sore throat, body aches, rash or diarrhea. Two children had concurrent gram negative bacteremia. Ten children (58.8%) required hospitalisation, 23.5% required oxygen and two had intensive care unit admission. One death was reported in this study. Chemotherapy was modified in five children, while elective surgery, chemotherapy and radiotherapy schedule were affected in eight children. Overall, the spread of Covid-19 was limited, the course of disease was mild, and anticancer treatment was provided and continued as per standard protocols. Key Words: Covid -19, Cancer, Anticancer chemotherapy, Immunosuppression, Children.

Discrepancy between PCR based SARS-CoV-2 tests suggests the need to re-evaluate diagnostic assays.

OBJECTIVE: We investigated the discrepancy between clinical and PCR-based diagnosis of COVID-19. We compared results of ten patients with mild to severe COVID-19. Respiratory samples from all cases were tested on the Roche SARS-CoV-2 (Cobas) assay, Filmarray RP2.1 (bioMereiux) and TaqPath™ COVID19 (Thermofisher) PCR assays. RESULTS: Laboratory records of ten patients with mild to severe COVID-19 were examined. Initially, respiratory samples from the patients were tested as negative on the SARS-CoV-2 Roche® assay. Further investigation using the BIOFIRE® Filmarray RP2.1 assay identified SARS-CoV-2 as the pathogen in all ten cases. To investigate possible discrepancies between PCR assays, additional testing was conducted using the TaqPath™ COVID19 PCR. Eight of ten samples were positive for SARS-CoV-2 on the TaqPath assay. Further, Spike gene target failures (SGTF) were identified in three of these eight cases. Discrepancy between the three PCR assays could be due to variation in PCR efficiencies of the amplification reactions or, variation at primer binding sites. Strains with SGTF indicate the presence of new SARS-CoV-2 variant strains. Regular modification of gene targets in diagnostic assays may be necessary to maintain robustness and accuracy of SARS-CoV-2 diagnostic assays to avoid reduced case detection, under-surveillance, and missed opportunities for control.

Outcome of first relapse of Hodgkin lymphoma: single institution experience.

OBJECTIVE: To determine outcome of first relapse of Hodgkin lymphoma with standard dose chemotherapy, and to identify the prognostic factors predicting survival outcome in paediatric patients. METHODS: The retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of Hodgkin lymphoma patients who relapsed at least 3 months after the completion of initial treatment from January 2001 to December 2010. Probabilities of overall survival, event-free survival and cumulative incidence were calculated. Data was analysed using SPSS 21. RESULTS: Of the 43 patients, 31(72%) were males and 12(29%) were females. Mean age at relapse was 11±3.3 years (range: 4-17 years). In 31(72%) patients, early post-operative intraperitoneal chemotherapy was employed. Median follow-up of the cohort was 62 months (interquartile range: 4-187 months). Overall survival and event-free survival at 10 years was 23(54%) and 15(35%) respectively. On univariate analysis, initial disease stage (p=0.021), stage at relapse (p=0.003), treatment protocol (p=0.005), treatment responsiveness at initial two cycles of salvage chemotherapy (p=0.002) and at the end of treatment assessment (p=0.0009) were statistically significant factors. Multivariate cox regression analysis revealed disease stage at relapse (p=0.004), chemotherapy regimen (p=0.025) and end-of-treatment disease evaluation (p=0.005) as the significant variables. CONCLUSIONS: Improved outcome with early post-operative intraperitoneal chemotherapy regimen was noted for Hodgkin lymphoma patients who had disease-free interval >2 years.

Kinome-Wide RNAi Screen Uncovers Role of Ballchen in Maintenance of Gene Activation by Trithorax Group in Drosophila.

Polycomb group (PcG) and trithorax group (trxG) proteins are evolutionary conserved factors that contribute to cell fate determination and maintenance of cellular identities during development of multicellular organisms. The PcG maintains heritable patterns of gene silencing while trxG acts as anti-silencing factors by conserving activation of cell type specific genes. Genetic and molecular analysis has revealed extensive details about how different PcG and trxG complexes antagonize each other to maintain cell fates, however, the cellular signaling components that contribute to the preservation of gene expression by PcG/trxG remain elusive. Here, we report an ex vivo kinome-wide RNAi screen in Drosophila aimed at identifying cell signaling genes that facilitate trxG in counteracting PcG mediated repression. From the list of trxG candidates, Ballchen (BALL), a histone kinase known to phosphorylate histone H2A at threonine 119 (H2AT119p), was characterized as a trxG regulator. The ball mutant exhibits strong genetic interactions with Polycomb (Pc) and trithorax (trx) mutants and loss of BALL affects expression of trxG target genes. BALL co-localizes with Trithorax on chromatin and depletion of BALL results in increased H2AK118 ubiquitination, a histone mark central to PcG mediated gene silencing. Moreover, BALL was found to substantially associate with known TRX binding sites across the genome. Genome wide distribution of BALL also overlaps with H3K4me3 and H3K27ac at actively transcribed genes. We propose that BALL mediated signaling positively contributes to the maintenance of gene activation by trxG in counteracting the repressive effect of PcG.

Frequency of Infectious Mortality at the End of Induction Chemotherapy in Acute Lymphoblastic Leukemia and Lymphoma Patients: Findings From a Tertiary Care Cancer Center.

Background and objective In low- and low-to-middle-income countries (LMICs), the incidence of treatment-related mortality (TRM) in patients with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) is up to 52%. This study aimed to determine the mortality rate at the end of the induction phase of the treatment among patients with ALL and lymphoma at a tertiary care cancer center. Methods This retrospective study analyzed outcomes after induction chemotherapy in pediatric patients with acute leukemia and lymphoma at a tertiary care cancer center from January 2015 to December 2016. Information regarding demographics, clinical characteristics, and laboratory investigations were extracted and reviewed. Results Of the total 160 patients, 110 were males, and the mean age of the sample was 4.6 +2.8 years. B-cell leukemia (pre-B-ALL) was diagnosed in 84% (n=134), while 10% (n=6) had acute T-cell leukemia (pre-T-ALL) and 6% (n=10) had lymphoma. Sixteen patients (10%) died within the defined induction period, with 14 deaths occurring due to infections and two deaths resulting from chemotherapy-related toxicity. Conclusion Based on our findings, there is a significant prospect of mortality from infections during induction chemotherapy in patients with pediatric hematological malignancies.

Spectrum of Fungal Pathogens in Burn Wound Specimens: Data From a Tertiary Care Hospital Laboratory in Pakistan.

Burn patients are at great risk of developing fungal wound infections. Fungi are frequently cultured from burn tissue specimens alone or in combination with bacteria. However, the spectrum of fungi in burn patients from Pakistan has not been reported previously. A retrospective laboratory-based study was conducted and data on all positive cultures from burn wounds were included. During the study period, specimens were cultured on appropriate media and incubated for anaerobic and aerobic growth. Clinical and demographic information recorded during clinical reporting was also collected. Seventy tissue cultures were positive for microorganisms. Of these, 27 (39%) had growth of either filamentous mold (17 cases) or Candida species (14 cases). Two cases had growth of both mold and yeast. Aspergillus flavus was the most common mold (9) followed by Fusarium species (3). Candida tropicalis was the most common yeast (7) followed by Candida parapsilosis (4). There was concomitant bacterial growth in 19 cases, predominantly of Staphylococcus aureus (13), Pseudomonas aeruginosa (8), and other Gram-negative rods (6). Of the 35 patients in which treatment history was available, 33 were receiving broad-spectrum antibiotics. A high incidence of fungal isolation was seen in this study. Their findings are consistent with the global increase in fungal infections in burn wounds. High index of suspicion by clinicians and revision of culture protocols in burn patients may be warranted for optimal patient management.

Clinical Characteristics and Treatment Outcome of Paediatric Rhabdomyosarcoma; A Retrospective Review.

Introduction: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. This paper aimed to assess the stage, site and treatment outcome among RMS patients. Materials and Methods: A retrospective chart review was completed from January 2011 to December 2017 of patients that presented to the Department of Paediatric Oncology, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, for the management of RMS. Data collection included clinical characteristics, staging, grouping, risk stratification, treatment plan, radiotherapy doses and treatment outcome. Results: Among 24 subjects, there were a total of 13 (54.2%) males and 11 (45.8%) females. The median age at the time of diagnosis was 2.5 years (range: 0.75-17 years). The majority of the subjects (91.7%) were <10 years of age. The median follow-up time was 0.6 years. According to the Children's Oncology Group Classification, 4 (16.7%) subjects were classified as low risk, 14 (58.3%) subjects were rated as intermediate risk and 6 (0.25%) subjects were stratified as high risk. The most common primary tumour site was genitourinary (62.5%) and abdomen/retroperitoneal (20.8%) regions. At the time of analysis, nine (37.5%) subjects had died because of the disease, 12 (50%) were alive with no evidence of disease and one subject had a recurrence of disease and was alive. One subject had abandoned the therapy and another was lost to follow-up. Conclusion: Patients with RMS presented at the late stages of the disease and it most frequently affected genitourinary and abdomen or retroperitoneal areas. Overall, RMS was found to have a poor outcome to therapy.

'Breakpoint broth microdilution plate' for susceptibility testing of Gram negative bacilli against colistin sulfate.

The MIC method applicable to Gram negative bacilli including Acinetobacter spp. is broth microdilution (BMD). Cost and/or availability issues limit the use of commercial MIC panels in resource limited settings. OBJECTIVES: To design and implement an in-house breakpoint BMD panel (BBMD) for colistin against Gram negative bacilli. DESIGN: BBMD panel was prepared in 96-well plate. MIC concentrations of 1, 2, & 4 â€‹µg/mL for test, and 0.25, 0.5, 1, 2 & 4 â€‹µg/mL for control strains were selected to accommodate 19 test and 3 quality control strains per plate. Plates were frozen at -80 â€‹°C until testing. Validation was performed using strains from a previously published study and compared with freshly prepared MIC panel of 16-0.03 â€‹µg/mL. RESULTS: Validation showed 100% agreement with the reference method and BBMD was introduced into routine laboratory practice for colistin susceptibility of carbapenem resistant Enterobacterales (CRE), Acinetobacter baumannii complex and Pseudomonas aeruginosa. From 2nd July-16th September 2018, a total of 1294 (mean 16.8 â€‹± â€‹5.5 isolates/day) clinical isolates were tested; 1157/1294 were reported (MIC ≤2 â€‹µg/mL) within 24-h, whereas 133 required resistance confirmation by full-range BMD. Resistance was confirmed for all but 24 isolates. These discrepancies were mostly due to contamination with bacterial genera inherently resistant to colistin. CONCLUSION: This BBMD plate is a high through-put and practical method that could reliably be utilized in a routine microbiology laboratory for colistin susceptibility testing of CRE, A. bauamanii complex and P. aeruginosa.