Barriers and Facilitators of Quality Family-Centered Communication in Pakistan.

PURPOSE: Communication is a fundamental aspect of patient- and family-centered care. Unfortunately, there is a dearth of evidence regarding pediatric cancer communication in low- and middle-income countries, where over 90% of all children with childhood cancer live. The purpose of this study was to explore barriers and facilitators of quality communication within two pediatric cancer centers in Pakistan. METHODS: Semistructured interviews were conducted with 20 multidisciplinary pediatric cancer clinicians and 18 caregivers of children with cancer at Children's Hospital of Lahore and Indus Hospital in Karachi, Pakistan. Interviews were conducted in English or Urdu, audio-recorded, transcribed, and translated to English. Two researchers coded each transcript using an inductively derived codebook. Thematic content analysis focused on barriers and facilitators of high-quality communication. RESULTS: Pakistani clinicians and caregivers identified factors that affected the quality of patient-centered cancer communication. These included structural factors including setting, available interpreters, documentation, patient volume, teamwork, and financial support. Clinician-level communication barriers and facilitators included communication training, clinician distress/boundaries, and the ability to have recurrent conversations. Patient or family characteristics affecting communication included education, income status, primary language, and geography; the child's specific disease type; and relational elements such as social support, empowerment, and split decision makers. Participants identified existing or potential interventions related to each factor. CONCLUSION: Multilevel factors serve as either barriers or facilitators for pediatric cancer communication in Pakistan. Identification of these elements of communication is an essential step toward interventions aimed at improving patient- and family-centered care in resource limited settings.

Neural Correlates of Optimal Deep Brain Stimulation for Cervical Dystonia.

A total of 15 individuals with cervical dystonia and good outcome after pallidal deep brain stimulation underwent resting-state functional magnetic resonance imaging under three conditions: stimulation using a priori clinically determined optimal settings (ON-Op), non-optimal settings (ON-NOp), and stimulation off (OFF). ON-Op > OFF and ON-Op > ON-NOp were both associated with significant deactivation within sensorimotor cortex (changes not seen with ON-NOp > OFF). Brain responses to stimulation were related to individual long-term clinical improvement (R = 0.73, R2 = 0.53, p = 0.001). The relationship was consistent when this model included four additional patients with generalized or truncal dystonia. These findings highlight the potential for immediate imaging-based biomarkers of clinical efficacy. ANN NEUROL 2022;92:418-424.

3T MRI of rapid brain activity changes driven by subcallosal cingulate deep brain stimulation.

Deep brain stimulation targeting the subcallosal cingulate area, a hub with multiple axonal projections, has shown therapeutic potential for treatment-resistant mood disorders. While subcallosal cingulate deep brain stimulation drives long-term metabolic changes in corticolimbic circuits, the brain areas that are directly modulated by electrical stimulation of this region are not known. We used 3.0 T functional MRI to map the topography of acute brain changes produced by stimulation in an initial cohort of 12 patients with fully implanted deep brain stimulation devices targeting the subcallosal cingulate area. Four additional subcallosal cingulate deep brain stimulation patients were also scanned and employed as a validation cohort. Participants underwent resting state scans (n = 78 acquisitions overall) during (i) inactive deep brain stimulation; (ii) clinically optimal active deep brain stimulation; and (iii) suboptimal active deep brain stimulation. All scans were acquired within a single MRI session, each separated by a 5-min washout period. Analysis of the amplitude of low-frequency fluctuations in each sequence indicated that clinically optimal deep brain stimulation reduced spontaneous brain activity in several areas, including the bilateral dorsal anterior cingulate cortex, the bilateral posterior cingulate cortex, the bilateral precuneus and the left inferior parietal lobule (PBonferroni < 0.0001). Stimulation-induced dorsal anterior cingulate cortex signal reduction correlated with immediate within-session mood fluctuations, was greater at optimal versus suboptimal settings and was related to local cingulum bundle engagement. Moreover, linear modelling showed that immediate changes in dorsal anterior cingulate cortex, posterior cingulate cortex and precuneus activity could predict individual long-term antidepressant improvement. A model derived from the primary cohort that incorporated amplitude of low-frequency fluctuations changes in these three areas (along with preoperative symptom severity) explained 55% of the variance in clinical improvement in that cohort. The same model also explained 93% of the variance in the out-of-sample validation cohort. Additionally, all three brain areas exhibited significant changes in functional connectivity between active and inactive deep brain stimulation states (PBonferroni < 0.01). These results provide insight into the network-level mechanisms of subcallosal cingulate deep brain stimulation and point towards potential acute biomarkers of clinical response that could help to optimize and personalize this therapy.

Safety assessment of spine MRI in deep brain stimulation patients.

OBJECTIVE: Many centers are hesitant to perform clinically indicated MRI in patients who have undergone deep brain stimulation (DBS). Highly restrictive guidelines prohibit the use of most routine clinical MRI protocols in these patients. The authors' goals were to assess the safety of spine MRI in patients with implanted DBS devices, first through phantom model testing and subsequently through validation in a DBS patient cohort. METHODS: A phantom was used to assess DBS device heating during 1.5-T spine MRI. To establish a safe spine protocol, routinely used clinical sequences deemed unsafe (a rise in temperature > 2°C) were modified to decrease the rise in temperature. This safe phantom-based protocol was then used to prospectively run 67 spine MRI sequences in 9 DBS participants requiring clinical imaging. The primary outcome was acute adverse effects; secondary outcomes included long-term adverse clinical effects, acute findings on brain MRI, and device impedance stability. RESULTS: The increases in temperature were highest when scanning the cervical spine and lowest when scanning the lumbar spine. A temperature rise < 2°C was achieved when 3D sequences were modified to 2D and when the number of slices was decreased by the minimum amount compared to routine spine MRI protocols (but there were still more slices than allowed by vendor guidelines). Following spine MRI, no acute or long-term adverse effects or acute findings on brain MR images were detected. Device impedances remained stable. CONCLUSIONS: Patients with DBS devices may safely undergo spine MRI with a fewer number of slices compared to those used in routine clinical protocols. Safety data acquisition may allow protocols outside vendor guidelines with a maximized number of slices, reducing the need for radiologist supervision.Clinical trial registration no.: NCT03753945 (ClinicalTrials.gov).

CONVERSION OF LAPAROSCOPIC CHOLECYSTECTOMY INTO OPEN CHOLECYSTECTOMY: AN EXPERIENCE IN 300 CASES.

BACKGROUND: Laparoscopic cholecystectomy is getting popularity in developing countries especially in Pakistan. Conversion from laparoscopic to open cholecystectomy is also common. This study intends to evaluate the causes of conversion from laparoscopic cholecystectomy to open cholecystectomy and to establish the efficacy and safety of the procedure. METHODS: This descriptive case series was conducted in the department of General Surgery at Social Security Teaching Hospital Islamabad from November 2012 to October 2015. Patients of more than 20 years of age presenting in OPD with symptomatic gallstones were included in the study. Patients with dilated CBD (> 8 mm in diameter), jaundice, acute cholecystitis, mass at porta hepatis and positive hepatitis B or C virology were excluded. RESULTS: A total of 300 patients were included in the study; 262 (87.33%) were females and 38 (12.67 %) were males. Twenty-one (7%) patients were converted to open cholecystectomy. Most common cause of conversion was dense adhesions followed by obscure anatomy at Calot's triangle. Other common causes were bleeding, bile leakage, visceral injuries and instrument failure. In the first 100 cases, 10% patients were converted to open cholecystectomy followed by 6% in the next 100 cases. Only 5% patients were converted to open cholecystectomy in the last 100 cases. CONCLUSION: Most common cause of conversion from laparoscopic cholecystectomy to open cholecystectomy was dense adhesions followed by obscure anatomy at Calot's triangle.

COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY: AN EXPERIENCE OF 247 CASES.

BACKGROUND: Laparoscopic cholecystectomy needs lot of training and experience in developing countries like Pakistan. After the introduction of laparoscopic cholecystectomy several studies have been conducted to evaluate the complications of laparoscopic cholecystectomy and to establish the efficacy and safety of the procedure. The aim of this study was to determine the complications of laparoscopic-cholecystectomy in a teaching hospital during the learning process. METHODS: This descriptive case series was conducted in the department of General Surgery at Social Security Teaching Hospital, Islamabad, from October 2012 to February 2015. Patients of more than 15 years of age having symptomatic gallstones were included. Patients with dilated common bile duct (>8 mm in diameter), jaundice, acute cholecystitis, mass at porta hepatis and positive hepatitis B or C virology were excluded. RESULTS: A sample of 247 consecutive patients was studied. Of them, 218 (88.26%) were females and 29 (11.74%) were males. Their age ranged from 15 to 73 years (mean 45.37). Six (2.43%) patients developed epigastric port site wound infection. Four patients (1.62%) had bleeding. There was bile leakage in 2 (0.82%) patients postoperatively. Two patients (0.82%) had collection (haematoma) in pouch of Morrison. One patient (0.41%) had duodenal injury. Eighteen (7.29%) laparoscopic procedures were converted to open cholecystectomy. The mean postoperative hospital stay was 1.8 days. CONCLUSION: Complication rate is high in early learning phase of laparoscopic surgery which can be reduced with proper training of surgeons and they should perform these procedures under supervision of experienced laparoscopic surgeons during their learning phase.