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.

Clinical features and outcome in paediatric newly diagnosed immune thrombocytopenic purpura in a tertiary care centre.

OBJECTIVE: The study aimed to demonstrate the pattern of clinical presentations and outcome of acute Immune Thrombocytopenia (ITP) in our Centre. METHODS: A descriptive, observational study was conducted by collecting and analysing the data of 103 patients of acute ITP, ageing between 1-14 years, at The Children's Hospital, Lahore from January 2016 to December 2016. We collected the data regarding age, sex, clinical presentations, history of preceding viral infections, vaccination history, laboratory values, different treatment options used, and response to the treatment concerning complete response, partial response and poor responders. Statistical analysis performed by using IBM SPSS statistics version 20. RESULTS: We retrospectively, reviewed total 103 patients cases. The median age, at the time of presentation, was 5±3.4 years while mean age was 4.5±2.9 years. The male to female ratio was 1.28:1. Mean platelet count on presentation was 7 x 109/L (range: 0-24). Twenty three (22.3%), patients had the history of preceding illness. Bruises, petechiae, epistaxis and hematemesis remained the common presentations. Six (5.8%) patients showed spontaneous recovery while 97 (94%) patients received treatment for ITP. Overall, 71 (68.9%) showed a response after treatment. Sixty-two patients (59.22%) showed loss of response and received treatment again. Among these patients, thirty-four patients (33%) developed chronic disease. CONCLUSION: Majority of patients presenting to our tertiary care centre had severe acute ITP on presentation. After management and follow-up, almost 1/3 of the patients develop chronic disease hence the incidence of developing chronic disease remained high as compared to the other centers.

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.

Methods and complications of septic induced abortion in patients managed at a tertiary care hospital.

BACKGROUND: To study the methods used for the termination of pregnancy and associated complications of induced abortion. METHODS: This descriptive study was conducted in the department of obstetrics and gynaecology, Fauji Foundation Hospital Rawalpindi. One Hundred patients were included in the study who was admitted with the history of induced abortion. The patients were assessed by detailed history and thorough clinical examination according to the study protocol. Data was collected on a specially designed Performa. Patients were interviewed in privacy and factors contributing to termination of pregnancy like age, parity, socioeconomic status and contraceptive failure were determined. Methods used for the procedure, status of abortionist were asked. Complications were determined by history, clinical examination and ultrasound examination. In view of all above data recommendations of preventing unwanted pregnancies were made. RESULTS: All patients were married and 57% of women belonged to age group of 31-40 years. Fifty-four 54% were grand multipara. In 63% of patients, induced abortion was carried out by Dai's. Most commonly used method was instrumentation (72%). Financial problems (46.7% ) and high parity (40%) were the most common factors contributing to termination of pregnancy. Serious complications like uterine perforation with or without bowel injury were accounted in 13% of women, septicaemia in 61%, peritonitis in 15% and DIC in 2%. During the study period illegally induced abortion accounted for 2% maternal deaths. CONCLUSION: Prevalence of poverty, illiteracy, grand multiparity and non-compliance of contraception were strong determinants of induced abortion, instrumentation being the most commonly used procedure resulting in high morbidity and mortality.

Vaginal breech delivery: still a safe option.

BACKGROUND: Elective caesarean section has replaced vaginal delivery for term breech foetuses due to fear of complications of vaginal breech delivery. This increasing rate of caesarean section worldwide is alarming. It has not only led to increase in adverse consequences in subsequent pregnancies and future fertility but also loss of skills for vaginal breech delivery. This study was conducted to determine the safety of vaginal breech birth in terms of maternal and neonatal complications. METHODS: This cross sectional study was conducted at department of Obstetrics/Gynaecology, Ayub Medical College, Abbottabad from January 2004 to December 2011. One seventy-eight women having successful vaginal breech delivery of singleton term foetuses from 2004-2008 were selected. They were studied for neonatal complications like low Apgar score (AS) < 7 at 5 min, birth trauma, admission to neonatal intensive care units and perinatal mortality. Maternal complications including any genital tract trauma and post-partum haemorrhage (PPH) were also noted. RESULTS: There were 11243 deliveries during this period, including 674 breech presentations at term (incidence of breech 6%). Out of 178 successful vaginal breech deliveries, 8 (4.49%) neonates had AS < 7 at 5 min, and 6 (3.37%) neonates needed NICU admission. There were no cases of birth trauma or perinatal morbidity. Maternal complications occurred in only 5 (2.8%) patients, 2 (1.1%) having perineal tears, 2 (1.12%) retained placenta and one (0.56%) case of post partum haemorrhage. CONCLUSION: Vaginal breech delivery can be safely undertaken without compromising maternal and neonatal outcome if strict criteria are met before and during labour.

Membership inference attack on differentially private block coordinate descent.

The extraordinary success of deep learning is made possible due to the availability of crowd-sourced large-scale training datasets. Mostly, these datasets contain personal and confidential information, thus, have great potential of being misused, raising privacy concerns. Consequently, privacy-preserving deep learning has become a primary research interest nowadays. One of the prominent approaches adopted to prevent the leakage of sensitive information about the training data is by implementing differential privacy during training for their differentially private training, which aims to preserve the privacy of deep learning models. Though these models are claimed to be a safeguard against privacy attacks targeting sensitive information, however, least amount of work is found in the literature to practically evaluate their capability by performing a sophisticated attack model on them. Recently, DP-BCD is proposed as an alternative to state-of-the-art DP-SGD, to preserve the privacy of deep-learning models, having low privacy cost and fast convergence speed with highly accurate prediction results. To check its practical capability, in this article, we analytically evaluate the impact of a sophisticated privacy attack called the membership inference attack against it in both black box as well as white box settings. More precisely, we inspect how much information can be inferred from a differentially private deep model's training data. We evaluate our experiments on benchmark datasets using AUC, attacker advantage, precision, recall, and F1-score performance metrics. The experimental results exhibit that DP-BCD keeps its promise to preserve privacy against strong adversaries while providing acceptable model utility compared to state-of-the-art techniques.

Acute leukaemia in children with Down syndrome in a low middle-income country.

Down syndrome (DS) is the commonest chromosomal disorder and is considered to be the most common syndrome associated with acute leukaemia. The objective of this study was to determine the characteristics of acute leukaemia in children with DS in Pakistan. It was a retrospective, cohort study conducted over a 2-year period, and the data was analysed in SPSS 20.0 in terms of descriptive statistics. Nineteen DS patients with acute leukaemia were enrolled. The proportion of DS-acute leukaemia was found to be 1.84% among all cases of paediatric acute leukaemia. The mean age of presentation was 5.5 years ± 4.3 SD with a male to female ratio of 1.1:1. The precursor B-cell ALL was found in 13 (68.4%) and acute myeloid leukaemia was found in 6 (31.6%) patients of DS. Thirteen patients (68.4%) completed treatment, while 6 (31.6%) expired due to treatment-related toxicity. Mean overall survival was 38 months ± 5.34 SD. The status of diagnosis of DS before presentation with acute leukaemia was the only statistically significant factor associated with the outcome. Few distinct characteristics of DS-acute leukaemia have been found in our population. Treatment toxicity was the sole cause of treatment failure.

Frequency of maternal mortality and morbidity in pregnancy-induced hypertension.

BACKGROUND: Pregnancy-induced hypertension (PIH) is defines as hypertension in pregnancy, and is sustained blood pressure >140 mm Hg systolic or 90 mm Hg diastolic. Objective of this study was to see the maternal outcome in terms of morbidity and mortality in PIH. METHODS: This descriptive study was conducted in Obstetrics and Gynaecology Unit of Fauji Foundation Hospital, Rawalpindi from January to December 2010. Both booked and un-booked cases were selected after fulfilling inclusion criteria. A detailed history and clinical examination was recorded and relevant investigations were performed. Patients were monitored for rise in blood pressure, development of complications related to hypertensions in pregnancy as well as maternal and perinatal outcome. RESULTS: During this period, 100 patients were admitted with pregnancy-induced hypertension. Majority were un-booked. Primigravida were 60 (60%), and were in age group 21-30 year, remaining were above 30 year. Four patients had placental abruption, 2 pulmonary oedema, 5 HELLP syndrome, 2 severe renal impairment, 20 elevated liver enzyme, 23 uncontrolled blood pressure, 20 server preeclampsia, 10 thrombocytopenia, 3 eclampsia, 10 had impaired coagulation profile, and 1 had maternal death. CONCLUSION: Pregnancy induced hypertension is a major cause of maternal mortality and morbidity. In Pakistan, its incidence and related mortality are high due to lack of adequate antenatal care.

Frequency of fibroid uterus in multipara women in a tertiary care centre in Rawalpindi.

BACKGROUND: At least 20% of all women and 40% of women over the age of 40 years have uterine leiomyomas. They distort the overlying endometrium and can become extruded or pedunculated (fibroid polyp) in the endometrial canal. The diagnosis of myomas is usually based upon the finding of an enlarged, mobile uterus with an irregular contour on bimanual examination or an incidental finding on transabdominal sonography. The objective of this study was to study the frequency of fibroid uterus in multipara women as observed by physical examination and ultrasonography. METHODS: During this descriptive study period all the patients reporting Fauji Foundation Hospital with menstrual irregularity partly and fulfilling the inclusion criteria were included. RESULTS: Out of 140 patients with fibroid uterus presenting to gynaecology department 108 (77.14%) were multiparous while 32 (22.86%) were primiparous. The mean parity was 5. The mean maternal age came to be 46 years. Most common presenting complaint of patients with uterine leiomyoma in this study was menstrual irregularity with menorrhagia in 42 (38.9%), metrorrhagia in 28 (25.9%), polymenorrhagia in 8 (7.4%) patients. The other presenting complaint was abdominal mass which was seen in 25 (23.1%). CONCLUSION: Multiparous patients were found to have fibroids more frequently than nulliparous in their perimenopausal years, which shows their characteristic slow growth rate. The most common manifestation was menorrhagia.

Endometrial pathology by endometrial curettage in menorrhagia in premenopausal age group.

BACKGROUND: Menorrhagia is objectively defined as blood loss greater than 80 ml or menstrual period lasting longer than 7 days. Dysfunctional uterine bleeding is responsible for 80% cases of Menorrhagia. Objective of this study was to find out the endometrial pathology and usefulness of hysterocopic directed endomentrial sampling in patient having menorrhagia in premenopausal age group. METHODS: This prospective descriptive study was conducted at Unit 1 of the Department of Obstetrics and Gynaecology, Fauji Foundation Hospital Rawalpindi, Pakistan from January to December 2007. During the study period, 100 patients with menorrhagia in age group 35-50 years were selected after fulfilling the inclusion criteria. These patients were selected from Gynaecology out patient department. After detailed history, examination and ultra sonography, they were admitted and hysteroscopic directed endometrial sampling was done endometrial samples were sent for histopathology to find out the endometrial pathology. RESULTS: The selected patients of my study with menorrhagia were scattered over all premenopusal age groups > 35 years. It was observed that 67 patient were above the age of 40 years. The analysis of histopathology reports of endometrial curettage revealed proliferative endomentrium in 33%, cystic hyperplasia's in 25% and carcinoma endometrium in one case. Cystichyperplasia and proliferative endometrium were found in menorrhagic women over 40 years of age. Adenoicarcinoma was found in a single premenopausal women of 48 years. CONCLUSION: All patients having menorrhagia above 40 years should be screened for any endometrial pathology. Accurate analysis of endometrial sampling is the key to effective therapy and optimal out come.

Late Morbidity among Survivors of Childhood Cancers; Experience at Tertiary Care Cancer Hospital.

Background: Long-term survivors of childhood malignancies are at increased risk of experiencing treatment-related morbidities. Survival into late adulthood in these children provides ample time for the acquisition of long-term sequelae. This study aimed to determine the late adverse effects among long-term survivors of childhood cancer from a low-income country perspective. Materials and Methods: Data were retrospectively collected from review of charts of patients aged under 18 years at the time of their primary diagnosis between 1 January, 1995, and 31 December, 2008, and who survived for at least 5 years after completion of their treatment. Analysed data included demographics, cancer type, treatment modality, types of chemotherapy agents administered and specific late morbidities including frequency of azoospermia, oligospermia, endocrine abnormalities, hearing and pulmonary function impairment and cardiac dysfunction among the long-term survivors of cancer. Results: The total number of patients was 300 with a mean age of 18 ± 2 years. The male to female ratio was 2.7:1. Median follow-up duration was 18 years (range: 5-25 years). Seventy-seven percent of patients were from Punjab, 20% were from Khyber Pakhtunkhwa and 3% were from other provinces. Fifty percent had a diagnosis of Hodgkin lymphoma, 17% had acute lymphoblastic leukaemia, 13% had non-Hodgkin lymphoma, 10% had germ cell tumours and 10% had other tumours. Fifty-seven percent received chemotherapy, 23% had chemotherapy and radiotherapy, 15% had chemotherapy and surgery, 3% had chemotherapy, surgery and radiotherapy and 2% had only surgery. Notable long-term documented sequelae were; azoospermia/oligospermia in 64%, endocrine abnormalities in 25% with hypothyroidism in 13.5% and follicle-stimulating hormone and luteinizing hormone abnormalities in 11.5%, ototoxicity in 6.5%, impaired pulmonary function tests in 4.6%, cardiotoxicity in 2.4% and second malignancies (acute myeloid leukaemia and myelodysplastic syndrome) in 1%. Conclusion: Childhood cancer survivors are at increased risk of adverse treatment-related sequelae and a long-term follow-up plan should be in place in centres where they receive treatment for their primary disease.

Efficacy Of 17- Α-Hydroxy-Progestrone In Prevention Of Preterm Labour In High Risk Pregnant Women.

BACKGROUND: Preterm delivery (before 37 completed weeks of gestation) is a major determinant of infant mortality. The objective of study was to determine the efficacy of 17-alpha hydroxyprogesterone in preventing delivery before 37 weeks of gestation in high risk women. METHODS: This study, a randomized controlled trial was conducted in Obstetrics OPD, observing all scientific and ethical protocols. The women with less than 20 weeks gestation and with a past history of preterm delivery were included. A total of 132 women fulfilled the study requirements. Two groups made were as follows: Group A (Treatment group received intramuscular 17-alpha hydroxy-progesterone) and Group B served as control (The control group revived intramuscular Neurobion). A total of 66 women were assigned to each group. The data was recorded on a specially designed proforma for statistical analysis and comparison following the standard procedure. RESULTS: The criterion was strictly observed. The results showed a statistically significant (p<0.01) difference between group A as compared to group B. CONCLUSIONS: 17-α- Hydroxyprogesterone was found to be an effective drug in preventing delivery before 37 weeks in women at risk.