Financial burden and social implications of chronic liver disease in a patient population group in Pakistan.

Objective: To assess economic and social issues faced by cirrhotic patients & its financial burden for developing nations like Pakistan. Method: This cross-sectional study was carried out at the Department of Gastroenterology & Hepatology, Shaikh Zayed Hospital, Lahore, Pakistan during the period between July & December 2019. Patients with liver cirrhosis were recruited and information regarding disease, financial status, treatment expenses & dependency was recorded. Results: A total of 450 patients were recruited, 272 (60%) were males & 178 (40%) were females, with mean age 55.4±6.2 years. HCV was cause of cirrhosis in 86% of cases, 65% were diagnosed incidentally and 39.6% were illiterate. About 82.7% were urban while only 28.7% own their own home. Co-morbid conditions including diabetes, hypertension & ischemic heart disease were present in 54% of cases. Monthly income was

AKU Giant Pituitary Adenoma Score: A Novel Scoring System to Predict the Outcomes of Surgery for Giant Pituitary Adenomas.

Background No scoring system is available to predict the extent of resection of giant pituitary adenomas (GPAs) based on magnetic resonance imaging (MRI) parameters. We developed a novel AKU Giant Pituitary Adenoma (AGPA) score and assessed the predictive ability of the scoring system concerning the extent of resection of GPAs. Methodology We retrospectively collected data of patients presenting with GPAs and used our scoring system to assess the surgical resection of these tumors. The Lundin-Pederson (ABC/2) method was used to calculate the pre- and post-resection tumor volume. The relationship between the extent of resection and the AGPA score was assessed using linear regression. The AGPA score considered the tumor's extension into various planes. The maximum total score was 9. Results The scoring system was applied to 45 patients with GPA who underwent surgical resection. The mean resected tumor volume (%) was 82.0 ± 16.7, and the overall mean AGPA score was 4.2 ± 0.8. The pairwise correlation between the resected tumor volume and the overall AGPA scores showed a strong inverse association (r = -0.633, p < 0.001). A significant difference was detected between the estimated scores of 3 and 5 and 4 and 5 (p < 0.001). Conclusions AGPA score is inversely related to the extent of the tumor to be resected, which would help surgeons predict the amount of tumor resection possible as well as predict the difficulty of surgery and plan optimal preoperative patient counseling. In addition, it can predict if staging and a transcranial approach are required.

Prognostic implication of size on outcomes of pituitary macroadenoma: a comparative analysis of giant adenoma with non-giant macroadenoma.

BACKGROUND: Due to the differences in size and invasiveness when compared to non-giant macroadenomas (nGPAs), giant pituitary adenomas (GPAs) are considerably harder to resect. This study aimed to differentiate GPAs from nGPAs, based on the presenting complaints, surgical approaches, peri- and postoperative outcomes. METHODS: We retrospectively analyzed cases of pituitary macroadenomas that underwent surgical resection at a tertiary care hospital. GPAs were tumors greater than 4 cm in the largest dimension, while nGPAs were tumors smaller than 4 cm. 55 GPA patients and 70 nGPA patients from 2006 to 2017 were included. Demographic, perioperative, and post-operative outcomes were evaluated. Group comparisons for continuous variables were made using an independent t-test/Mann Whitney U test and categorical data was analyzed on Chi-square/Fisher exact test; a p-value of < 0.05 was considered significant. RESULTS: Visual deterioration was the most common complaint, reported by 61.4% of nGPA patients and 81.8% of GPA patients. The mean extent of gross total resection was 47.1% in nGPA patients and 18.2% in GPA patients (p = 0.001). After surgery, tumor recurrence was seen in 1.4% of nGPA patients and 18.2% of GPA patients (p = 0.001). First re-do surgery was required in 5.7% of nGPA patients and 25.5% of GPA patients (p = 0.004). CONCLUSION: Compared to nGPAs, GPAs are more likely to present with a higher number of preoperative symptoms, and lesser chances of gross total tumor resection. GPAs are also associated with a higher rate of recurrence, which results in more follow-up procedures. Larger, multi-center longitudinal studies need to be done to validate these findings.

Current Management Trends for Surgical Site Infection After Posterior Lumbar Spinal Instrumentation: A Systematic Review.

OBJECTIVE: The objective of this systematic review is to determine the fate of spinal implants when patients develop postoperative wound infection after posterior instrumental fusion in a degenerative spine. METHODS: A systematic review of the English-language literature (published between January 2001 and July 2020) was undertaken to identify articles documenting the management strategy for surgical site infections (SSIs) after posterior lumbar spinal fusion. Studies on pedicle screw fixation after trauma, immunocompromised, metastatic spine disease, and combined anterior/posterior approach were excluded. Two independent reviewers assessed the level of evidence quality using the criteria set by the North American Spine Society, and disagreements were resolved by consensus. RESULTS: Of the 3071 citations identified, 49 met the criteria to undergo full-text review. Outcomes after SSIs were studied from a combined pool of 1150 patients who had undergone instrumental spinal fusion. The collected data showed that 456 patients (39.97%) had undergone spinal implant removal after SSI while 694 patients (60.03%) had their implants retained until the resolution of SSI. There was an absolute risk reduction (ARR) of 29% (-0.292) and a relative risk reduction (RRR) of 50.3% (-0.503) of implant removal if the patient underwent wound debridement following SSI. The number needed to treat (NNT) for wound debridement was calculated at 3.31 from our pooled cohort. The ARR in implant removal following vacuum-assisted closure (VAC) therapy was 16.6% and RRR was noted at 40.4%. This led to a high value of NNT at 6.0 patients. There was an ARR of 33.5% and a RRR of 70.7% was estimated in patients undergoing continuous irrigation. CONCLUSIONS: Our review of the literature suggests that surgeons prefer early wound debridement with or without negative pressure wound therapy under antimicrobial coverage for eradication of SSI after posterior lumbar spinal fusion. Implant removal is generally reserved for cases refractory to the other treatment modalities.

Eccrine spiradenoma: a rare adnexal tumour with atypical presentation: A case report.

First described in 1934, eccrine spiradenoma (ES) is a rare, benign adnexal tumour arising from eccrine sweat glands. It commonly presents as a slow-growing nodule on the upper trunk, and head and neck region, mostly in the age bracket of 15-35 years, with no gender preference. While no established guidelines exist for optimal management of malignant ES, some therapies have been studied. The diagnosis of this entity is extremely important as it can harbour a malignant component with disastrous outcomes which may be missed due to its strong resemblance to benign lesions, such as a papilloma. Here, we present the case of a 35-year-old lady who presented with a papilloma-like growth on the upper medial aspect of the thigh which was diagnosed as eccrine spiradenoma upon excision.

Sofosbuvir-based Treatment for HCV: A Safe Option in Patients Undergoing Hemodialysis.

The objective of this study was to ascertain the safety and efficacy of sofosbuvir in patients undergoing hemodialysis. Twenty-three HCV infected patients undergoing hemodialysis were included. Sofosbuvir was administered in combinations with ribavirin, daclatasvir and ledipasvir for 12-24 weeks. Viral response was checked at the end and 12 weeks after completing therapy. Twenty-one (91.3%) were of genotype 3 and two (8.7%) genotype 1. Eight (34.8%) had cirrhosis. Three (13%) were previous relapsers to sofosbuvir and ribavirin, while one (4.3%) was relapser to interferon. Sofosbuvir plus ribavirin was given to four (17.4%), sofosbuvir plus daclatasvir to eleven (47.8%), sofosbuvir plus daclatasvir plus ribavirin to four (17.4%), sofosbuvir plus velpatasvir to three (13%), and sofosbuvir plus ledipasvir to one (4.3%) patient. Twenty-one (91.3%) achieved viral eradication on completion of treatment; two were non-responders. Nineteen (82.6%) had undetectable virus 12 weeks after ending treatment and remaining two (8.7%) relapsed. Adverse effects were not observed. Hence, sofosbuvir can be safely used in patients undergoing hemodialysis. Key Words: Sofosbuvir, Hemodialysis, Hepatitis C.

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan.

Approximately one half of patients develop ascites within 10 years of diagnosis of compensated cirrhosis. It is a poor prognostic indicator, with only 50% surviving beyond two years. Mortality worsens significantly to 20% to 50% at one year if the ascites becomes refractory to medical therapy. Pakistan has one of the highest prevalence of viral hepatitis in the world and patients with ascites secondary to liver cirrhosis make a major percentage of both inpatient and outpatient burden. Studies indicate that over 80% of patients admitted with ascites have liver cirrhosis as the cause. This expert opinion suggests proper assessment of patients with ascites in the presence of underlying cirrhosis. This expert opinion includes appropriate diagnosis and management of uncomplicated ascites, refractory ascites and complicated ascites (including spontaneous bacterial peritonitis (SBP) ascites, hepatorenal syndrome (HRS) and hyponatremia. The purpose behind this expert opinion is to help consultants, postgraduate trainees, medical officers and primary care physicians optimally manage their patients with cirrhosis and ascites in a resource constrained setting as is often encountered in a developing country like Pakistan.

Biological characteristics and outcomes of Gliosarcoma.

Gliosarcoma is a highly aggressive primary brain tumour. It is a relatively rare tumour and comprises of two histological components, glial and sarcomatous. Gliosarcomas carry a poorer prognosis than that of Glioblastoma Multiforme (GBM). The current review highlights important histological and radiological features of gliosarcoma in the light of recent literature, and also touches upon the treatment options and outcomes of various types of gliosarcoma.

Outcome of Endoscopic Management of Post Living Donor Liver Transplant Anastomotic Strictures.

OBJECTIVE: To evaluate the therapeutic efficacy of endoscopic dilatation of anastomotic stricture (AS). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, Pakistan from November 2016 to November 2017. METHODOLOGY: Patients presenting with anastomotic biliary stricture following living donor liver transplant (LDLT) underwent endoscopic retrograde cholangio-pancreaticography (ERCP) and treatment of their strictures with dilatation with or without stenting. The patients were then followed up to see adequate resolution of stricture and repeat therapeutic ERCP was performed, if required. The patients were labelled as cured if stricture resolution persisted for a period of up to six months following ERCP. RESULTS: Forty-three patients (32 males and 11 females), with post-LDLT AS, who met the inclusion and exclusion criteria were enrolled in the study. Thirty-six (83.7%) patients had a single biliary anastomosis while seven (16.3%) patients had two anastomoses. Ductoplasty was done in 15 (34.9%) of the enrolled patients. Patients with post-LDLT AS required 3.65 +1.15 sessions of ERCP. Plastic type biliary stent was used in seven (16.3%) patients, balloon dilatation alone was done in five (11.6%) patients and combined balloon dilatation and stent placement was performed in 29 (67.4%) patients, and combined graduated dilator and stent placement was performed in two (4.7%) patients. Five (11.6%) patients required rendezvous procedure (whereby a radiologist placed a guidewire percutaneously into the biliary system) as guidewire placement across stricture site was endoscopically unsuccessful. The overall success rate was 88.4%. Mean stent free follow-up was 7.18 +1.38 months. Recurrence of AS was noted in one (2.3%) patient. CONCLUSION: Endoscopic management of post-LDLT AS has an efficacious long-term outcome.

Management And Outcome Of Jaundice Secondary To Malignancies Of The Gall Bladder, Biliary Tree And Pancreas: A Single Centre Experience.

BACKGROUND: Obstructive jaundice due to malignancies of the biliary tree, gall bladder and pancreas account for a significant number of patients managed by tertiary centres. Management options are curative or palliative, depending on disease stage. This study was performed to see the effectiveness of treatment modalities for these patients and eventual outcome. METHODS: This cross-sectional analytical study was conducted at the Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital Lahore, from January 2015 to June 2016. All adult patients aged 18 and above of either sex presenting with obstructive jaundice secondary to malignant disease originating from the gallbladder, biliary-tree or pancreas were included in the study. The disease was staged after admission. The patients then underwent endoscopic, surgical or percutaneous drainage and were followed up for a period of one year. RESULTS: Two hundred & sixty-two patients presenting with jaundice due to malignancy arising from the biliary tree, gall bladder or pancreas were enrolled between January 2015 and June 2016, 141 (53.8%) males and 121 (46.2%) females. Eighty (30.5%) had cholangiocarcinoma, 70 (26.7%), had gall bladder tumours, 61 (23.3%) pancreatic cancer and 51(19.5%) had ampullary tumours. 31 (11.8%) patients had disease qualifying curative surgical resection. One hundred & eighty-five (70.6%) patients underwent palliative therapy in the form of percutaneous in 86 (32.9%) and endoscopic drainage in 126 (48.1%). Twenty-eight (10.7%) patients refused all treatment. Eighteen (6.9%) patients died before undergoing any therapeutic intervention. Thirty-three (12.6%) died during hospital stay. Survival at 3, 6 and 12 months was 49.2% (129 patients), 28.2% (74 patients) and 8.4% (22 patients), respectively. These 22 included all patients who had undergone curative resection. We attributed the largest number of deaths, 197 (75.2%) patients, to metastatic/advanced disease and associated complications. CONCLUSIONS: The results showed that patients with advanced disease who were only eligible for palliative therapy, at first presentation, constituted the majority of patients. These patients require skilled endoscopy and interventional radiology teams for successful biliary drainage.

Early Initiation Of Beta Blockers Following Primary Endoscopic Therapy For Bleeding Oesophageal Varices In Cirrhotics.

BACKGROUND AND AIMS: Beta-blockers provide secondary prophylaxis following endoscopic therapy for variceal bleeding. Guidelines recommend starting beta-blockers 6 days after endoscopy to prevent masking hemodynamic signs of re-bleeding. We aimed to see safety of earlier initiation of betablockers. METHODS: Cirrhotic patients with upper GI bleed were given intravenous vasoactive agents until undergoing endoscopy. Patients with only oesophageal varices as source of bleed were recruited. Vasoactive agents were discontinued following variceal banding. The patients were observed for 12-18 hours, discharged on oral carvedilol 6.25 mg BID and monitored for 6 weeks for re-bleeding and mortality. RESULTS: Fifty patients were included, 27 (54%) male and 23 (46%) female. Average age was 43±3 years. Aetiology of cirrhosis was HCV in 42 (84%), HBV in 6 (12%), HCV & HBV in 2 (4%) and indeterminate in 1 (2%) patient. Seventeen (34%) patients had Child A, 22 (44%) Child B and 11 (22%) had Child C disease. Hospital stay was under 24 hours in 24 (48%), 24-48 hours in 15 (30%) and 48-72 hours in 11 (22%) patients. Five (10%) patients underwent EGD within 6 hours of admission, 28 (56%) within 12 hours, 14 (28%) within 24 hours and 3 (6%) within 36 hours. No re-bleeding, mortality or drug related adverse effects were noted during 6 weeks after discharge. CONCLUSIONS: Our study proves possibility of shorter management of variceal bleeding by having a 12-18 hour monitoring after endoscopic banding, followed by beta-blocker initiation and discharge. This will safely reduce physical and financial burden on health services.

Comparison of 12-Hour with 72-Hour Terlipressin Therapy for Bleeding Esophageal Varices.

OBJECTIVE: To determine the efficacy of 12-hour of Terlipressin therapy as compared to 72-hour therapy in preventing rebleeding after endoscopic therapy. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: Department of Gastroenterology and Hepatology, Shaikh Zayed Hospital, Lahore, from January to March 2016. METHODOLOGY: Cirrhotic patients presenting to our hospital with GI (gastrointestinal) bleeding received Terlipressin 2 mg intravenous bolus, followed by 1mg 6-hourly until undergoing endoscopy. Those with esophageal varices as the source of bleeding underwent band ligation and were recruited. Of the 93 enrolled patients, 90 remained and were randomized into 25 (27.8%) in control Group-Aand 65 (72.2%) in test Group-B. Group-Areceived 72-hour of Terlipressin while Group-B received it for 12-hour. Both groups were monitored for rebleeding for 5 days. RESULTS: Rebleeding occurred in 1 (4%) patient in Group-Aand 3 (4.6%) in Group-B during the 5-day period. All 4 (4.4%) underwent repeat endoscopy. The Group-Apatient and 2 (3%) of 3 Group-B patients showed ulcers over band ligation sites as source of bleed. The third Group-B patient showed varices requiring repeat banding. One (4%) patient (Group-A) died due to persistent encephalopathy. No drug related adverse effects were seen. CONCLUSION: A12-hour duration of Terlipressin as an adjunct to endoscopic band ligation shows similar results to 72-hour therapy.

Accuracy of conventional MRI for preoperative diagnosis of intracranial tumors: A retrospective cohort study of 762 cases.

BACKGROUND: Conventional magnetic resonance imaging (MRI) is considered a valuable tool for preoperative diagnosis of intracranial tumors. We assessed its accuracy in the diagnosis of intracranial tumors in usual clinical practice. MATERIALS AND METHODS: MRI reports of 762 patients who had undergone conventional brain MRI prior to surgery were retrospectively reviewed. A 4-grade scoring system was devised to establish diagnostic agreement. Each tumor type was compared with the corresponding pathological diagnoses by dichotomization. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for the overall patient population as well as for each tumor type. RESULTS: 664 cases (87.1%) were tumor-positive, and 98 cases (12.9%) were tumor-negative. The most common tumor types were meningiomas, gliomas, pituitary adenomas and schwannomas. These four types together comprised 74.5% of all cases reviewed. Sensitivity and PPV for the overall population were 72.0-90.7% and 91.9-95.4%, respectively. Diagnostic accuracy differed among tumor types. Meningiomas, pituitary adenomas, schwannomas and cholesteatomas were more likely to be diagnosed correctly (sensitivities were 82.6-96.9%, 86.1-96.7%, 88.9-98.2% and 91.3-100.0%, respectively); while some other types like solitary fibrous tumors (SFTs) seemed difficult to identify. Gliomas tended to be confused with metastases, meningiomas with SFTs, and pituitary adenomas with craniopharyngiomas. CONCLUSION: The accuracy of conventional MRI for diagnosing intracranial tumors is generally satisfactory but should not be too heavily relied upon, especially for certain tumor types. In cases of discrepancy, neurosurgeons are encouraged to confer with the reporting neuroradiologists to achieve optimal preoperative diagnoses.

Cerebellopontine angle primitive neuroectodermal tumor mimicking trigeminal schwannoma.

BACKGROUND: Primitive neuroectodermal tumors (PNETs) comprise a group of aggressive, poorly differentiated embryonal tumors occurring in central nervous system as well as in peripheral locations. Primary cerebellopontine angle (CPA) PNET is an extremely rare entity. It is important to have knowledge of this pathology and to be able to differentiate it from other commonly occurring CPA tumors, such as vestibular and trigeminal schwannomas. This distinction is essential because of the difference in the overall treatment plan and prognosis. CASE DESCRIPTION: This report describes a case of a young male presenting with diplopia and numbness of face; magnetic resonance imaging showed a CPA mass. With a provisional diagnosis of trigeminal schwannoma, the patient underwent surgery. Histopathology provided a diagnosis of PNET. CONCLUSION: We discuss the importance of recognizing this rare condition and how this entity differs from the commonly occurring tumors.

Providing Care Beyond the Hospital: Perspective of a Tertiary Care Hospital from a Developing Country.

BACKGROUND: Neurorehabilitation is an important aspect of continuing care for neurosurgical patients with functional disability. In developing countries, where formal home nursing frequently is unavailable, ensuring care after discharge is a difficult task. Training attendants to provide nursing care is an alternate option. In this study, we compared the outcomes of patients nursed by family members versus those looked after by a professional nurse. METHODS: This was a retrospective observational study conducted at the Aga Khan University Hospital Karachi. The study consisted of 2 groups. Group 1 (consisting of patients cared for by a professional nurse) included 94 patients and group 2 (patients cared for by family members) included 102. All these patients had activity of daily living score of ≥3. Glasgow Outcomes Scale score, time to decannulation, development/worsening of bedsores, and mortality were recorded and compared between the groups at follow-up. RESULTS: The study included 196 patients. Traumatic brain injury was the most common diagnosis. Nursing requirements were similar between the 2 groups and included tracheostomy care, percutaneous endoscopic gastrostomy tube care, peripherally inserted central catheter line care, care of patients with no bone flap, and log-rolling. The outcomes of the 2 groups were comparable and included bedsore development/worsening of grade, Glasgow Outcomes Scale score at follow-up, time to decannulation, and 30-day mortality. CONCLUSIONS: There was no statistically significant difference in outcomes of patients nursed by family members compared with the patients looked after by professional nurses.

End Stage Renal Disease: Seroprevalence of Hepatitises B and C along with Associated Aetiology and Risk Factors in Children.

Background. End Stage Renal Disease (ESRD) normally requires dialysis or transplantation for survival. Since ESRD patients are on long term dialysis, infections such as Hepatitis B (HBV) and Hepatitis C (HCV) are commonly reported. Methods. This was a retrospective study carried out at a government hospital during a 12-month period from January 2013 to December 2013. The data was collected using a predesigned pro forma to note the etiology, gender, age, and HBsAg and anti-HCV test result of each patient. Results. 444 children suffering from ESRD were included in our analysis. The mean age of sample was 12.7 ± 4.1 years. Sixty percent (n = 262) of the children were boys. The most common etiology of ESRD was kidney stones (n = 44, 29.3%). HBV was positive in 11 children (2.5%) while HCV was positive in 13 (2.9%). Conclusion. This study asserts the need for carrying out further work to confirm these findings and expand our recommendations. It is imperative to reliably determine the burden of HBV and HCV disease and to determine the aetiology of their spread especially in children with ESRD.