Scalp metastasis from atypical meningioma: A case report and literature review.

Key Clinical Message: Scalp metastasis from atypical meningioma, though rare, underscores the importance of meticulous surgical techniques to prevent tumor cell implantation. Early detection and comprehensive management, including surgery and adjuvant therapy, are crucial for optimal outcomes. Abstract: Meningiomas are tumors of the meninges that originate in the arachnoid layer from arachnoid cap cells. Atypical meningiomas, classified as WHO grade 2 tumors, tend to metastasize and recur if not surgically managed properly. Scalp metastasis is a rare occurrence that presents as a subcutaneous elevation. A 33-year-old patient presented with a complaint of a constant, dull pressure headache persisting for the past 12 months, exacerbated by exertion, along with seizures and neuropsychiatric symptoms. The patient had no significant medical history but had undergone surgery 4 years ago for a WHO grade 2 meningioma. The current brain MRI revealed a dural tail sign, along with masses on both the left and right sides of the frontal lobe, extending to involve the skin on the forehead and scalp. The patient underwent surgical resection and adjuvant radiation therapy. At the 12-month follow-up, no neurological deterioration or tumor recurrence was observed. A literature review on scalp metastasis in patients with atypical meningioma was also conducted, including eight articles published up to September 2023. The mechanism of metastasis development appears to be consistent in all eight reported cases, involving the implantation of tumor cells during resection. Therefore, there is a critical need for meticulous intra- and post-operative surgical techniques to prevent such implantation.

Citrate silver nanoparticles impregnated cellulose as a photocatalytic filter in the degradation of organic dye in the aqueous media.

Photocatalysis is a clean and efficient process pursued under light irradiation with a suitable photocatalyst to degrade a contaminant. We report citrate functionalization of silver nanoparticles (SNPs) for effective immobilization on cellulosic fabric. The porous cellulosic matrix could be explored as microfiltration membranes for the photocatalytic degradation of organic dyes in the aqueous media. Where valid, the citrate functionalized SNPs and the treated cellulose fabrics were considered for optical, structural, surface chemical, thermal, textile, flowability, photocatalytic, and antibacterial attributes. The SNPs expressed the bandgap energy of 2.56 and 2.43 eV and Urbach energy of 3.38 and 5.21 eV before and after functionalization with the citrate moieties, respectively. The liquid chromatographic and FTIR analyses indicated that the crystal violet (CV) organic dye has been successfully photodegraded to environmentally safer and nontoxic species on passing the contaminated water through the SNPs-treated cellulosic filter. The spectroscopic data also supported the said outcomes. The results demonstrated that the citrate-SNPs-treated cellulose could be efficiently employed as antibacterial photocatalytic membranes for degrading organic dyes in the aqueous media for multiple cycles.

Impact of SSO-ASTRO Margin Guidelines on Re-excision Rate in Breast-conserving Surgery: A Single-center Experience.

Introduction: Breast-conserving surgery (BCS) has been historically linked with a high rate of re-excision. To address this issue, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) developed consensus guidelines in 2014 to standardize practices and improve clinical outcomes for BCS patients. In our tertiary cancer care hospital, we assessed the impact of these guidelines on the re-excision rate following BCS. Materials and Methods: We conducted a retrospective study on breast cancer patients who underwent BCS at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan. The study compared the re-excision rate before the implementation of the SSO-ASTRO consensus guidelines (November 2015-July 2017) and after the implementation (January 2018-August 2019). Margins were considered positive if "ink on tumor" was present and negative if "no ink on tumor" was present. Fisher's exact test or Chi-square test was used to compare the re-excision rates between the pre- and post-guideline periods. Results: A total of 919 patients were identified, with 533 from the pre-guideline period and 386 from the post-guideline period. Of the 919 patients, 31 with ductal carcinoma in situ (DCIS) were excluded from the re-excision analysis because the guidelines were not implemented on the DCIS. Furthermore, the overall rate of re-excision in our data was 4.3%. The re-excision rate decreased from 71.1% to 28.9% (P ≤ 0.05) following the adoption of the guidelines. We observed a statistically significant decrease in the re-excision rate after implementing the SSO-ASTRO guidelines. Conclusion: Implementation of the SSO-ASTRO margin guidelines led to a notable decrease in the overall re-excision rate in our data set. These findings suggest that continued adherence to the guidelines may lead to a further reduction in the re-excision rate in the future.

Beyond the Body: Using Photovoice to Explore Social Determinants of Diabetes With South Asian Adolescents in the Peel Region of Ontario, Canada.

OBJECTIVES: The higher prevalence of diabetes in the South Asian (SA) population living in Canada spans across generations and is often associated with individual risk factors while undermining the social determinants of health (SDOH). There is a scarcity of studies on the perspectives of SA adolescents with a family history of type 2 diabetes mellitus (T2DM). Learning directly from these adolescents can fill a major gap by providing insight on how the SDOH contribute to disproportionate rates of T2DM in SA immigrant communities. METHODS: In this study, we used Photovoice, which is a community-based participatory research (CBPR) method that involves the use of photography to visually capture the challenges of diabetes prevention from the perspective of those with lived experiences. A group of 15 SA youth were recruited from an adolescent diabetes education program in the Peel Region of Ontario. The youth discussed their images and accompanied written narratives during focus groups. RESULTS: Four themes emerged from the thematic analysis of the photographs and participant narratives that influence the manifestation of T2DM in SA communities: 1) immigration and resettlement stressors; 2) food insecurity; 3) unhealthy school environments; and 4) academic pressures. CONCLUSIONS: Findings suggest the need to address T2DM as a response to unjust conditions and environments rather than as an epidemic entrenched in genetic predisposition, culture, and poor lifestyle choices.

Differential roles of cyclooxygenase enzymes in the regulation of murine juvenile undifferentiated spermatogonia.

BACKGROUND: Acetaminophen and ibuprofen are widely administered to babies due to their presumed safety as over-the-counter drugs. However, no reports exist on the effects of cyclooxygenase inhibitors on undifferentiated spermatogonia and spermatogonial stem cells. Infancy represents a critical period for spermatogonial stem cell formation and disrupting spermatogonial stem cells or their precursors may be associated with infertility and testicular cancer formation. OBJECTIVES: The goal of this study was to examine the molecular and functional impact of cyclooxygenase inhibition and silencing on early steps of undifferentiated spermatogonia (u spg) and spermatogonial stem cell development, to assess the potential reproductive risk of pharmaceutical cyclooxygenase inhibitors. METHODS: The effects of cyclooxygenase inhibition were assessed using the mouse C18-4 undifferentiated juvenile spermatogonial cell line model, previously shown to include cells with spermatogonial stem cell features, by measuring prostaglandins, cell proliferation, and differentiation, using cyclooxygenase 1- and cyclooxygenase 2-selective inhibitors NS398, celecoxib, and FR122047, acetaminophen, and ibuprofen. Cyclooxygenase 1 gene silencing was achieved using a stable short-hairpin RNA approach and clone selection, then assessing gene and protein expression in RNA sequencing, quantitative real-time polymerase chain reaction, and immunofluorescence studies. RESULTS: Cyclooxygenase 2 inhibitors NS398 and celecoxib, as well as acetaminophen, but not ibuprofen, dose-dependently decreased retinoic acid-induced expression of the spg differentiation gene Stra8, while NS398 decreased the spg differentiation marker Kit, suggesting that cyclooxygenase 2 is positively associated with spg differentiation. In contrast, short-hairpin RNA-based cyclooxygenase 1 silencing in C18-4 cells altered cellular morphology and upregulated Stra8 and Kit, implying that cyclooxygenase 1 prevented spg differentiation. Furthermore, RNA sequencing analysis of cyclooxygenase 1 knockdown cells indicated the activation of several signaling pathways including the TGFb, Wnt, and Notch pathways, compared to control C18-4 cells. Notch pathway genes were upregulated by selective cyclooxygenase inhibitors, acetaminophen and ibuprofen. CONCLUSION: We report that cyclooxygenase 1 and 2 differentially regulate undifferentiated spermatogonia/spermatogonial stem cell differentiation. Cyclooxygenases regulate Notch3 expression, with the Notch pathway targeted by PGD2. These data suggest an interaction between the eicosanoid and Notch signaling pathways that may be critical for the development of spermatogonial stem cells and subsequent spermatogenesis, cautioning about using cyclooxygenase inhibitors in infants.

Synthesis of aminolyzed gelatin-mediated chitosan as pH-responsive drug-carrying porous scaffolds.

Bio-based drug delivery devices have gained enormous interest in the biomedical field due to their biocompatible attributes. Extensive research is being conducted on chitosan-based devices for drug delivery applications. Chitosan being hydrophobic under neutral conditions makes it difficult to interact with a polar drug of curcumin. We tended to make it polar through sol-gel synthesis and modification via PEGylation, alkaline hydrolysis, and aminolysis. Such alterations could make the chitosan-based scaffolds porous, hydrophilic, amino-functionalized, and pH-responsive. The ninhydrin assay confirmed that a successful aminolysis occurred, and the chemical interaction among the precursors was explained under infrared spectroscopy. The scanning morphology of the optimum aminolyzed membrane appeared to be porous with an average pore size of 320 ± 20 nm. The aminolyzed chitosan membrane was found thermally stable up to 310 °C, hydrophilic with a water contact angle of 23.4°, moderate flowablity, and porous (97 ± 5 %, w/w) against ethanol. The curcumin-loaded chitosan membrane expressed the UV-protection behavior of 99 %. The curcumin-loading and release phenomena were found pH-responsive. The curcumin release results were evaluated through specific kinetic models. This study could be the first report on the amphiphilic, porous, and swellable drug-loaded gelatin/chitosan membrane with pH-responsive loading and release of curcumin for potential drug delivery applications.

Benchmarking Excellence: Evaluating Advanced Breast Carcinoma Care in Pakistan's Largest Cancer Hospital Against the National Institute for Health and Care Excellence (NICE) Guidelines.

Introduction Breast cancer is the most common type of cancer worldwide, and even with all the screening and education, great numbers of diagnoses are made in advanced stages. Additionally, patients in remission always remain at risk of relapse and metastasis. Pakistan has the highest incidence of breast cancer among Asian countries. The purpose of this clinical audit was to compare data from the largest cancer hospital in Pakistan with international standards to provide room for quality improvement. Methods A retrospective review of patients with advanced breast carcinoma over a period of six months was done. Permission was obtained from the Quality Assurance and Patent Safety Department before the commencement of the audit. Standards Data obtained were audited against nine standards of four different categories from the National Institute for Health and Care Excellence (NICE) guidelines on advanced breast carcinoma. Results For the diagnosis and assessment category, for which a target of 100% was set, 99.66% was achieved; for disease monitoring, for which a target of 100% was set, 91.8% was achieved; for systemic disease-modifying therapy, for which the majority was the target, only 1% was achieved; for managing complications, for which a target of 100% was set, 71.8% was achieved. Conclusion Continuous research and breakthrough advancements have made health care an ever-evolving field. Clinical audits like these that compare international standards with local data are beneficial and lead to quality improvement. They highlight issues that may be overlooked otherwise, raise questions that may never be asked, and may inspire prospective research studies. Limitations of the audit were that this clinical audit was conducted outside of the NHS where NICE guidelines are not followed and local guidelines differ from NICE guidelines.

Fabrication of gelatin-incorporated nanoporous chitosan-based membranes for potential water desalination applications.

Membrane technology has extensively been used in diverse phenomena such as separation, purification and controlled transportation. Herein, gelatin-incorporated porous chitosan membranes have been prepared using the sol-gel approach for potential water desalination applications. The porogens of poly(ethylene glycol) and Triton X-100 were employed for the mentioned purpose. The prepared porous membranes have been characterized for surface chemical, structural, thermal, mechanical and functional attributes using appropriate analytical approaches. Electron microscopy expressed porous surface morphologies of the resultant films with an average pore size of 14.5 nm. The infrared analysis demonstrated a successful crosslinking of the precursors in the resulting membranes via maleic anhydride. Differential scanning calorimetry analysis disclosed acceptable thermal stability of the test membranes, workable above ambient temperatures. The membrane expressed a water contact of 68.59°, which indicated moderate hydrophilicity, thus allowing controlled transport of the aqueous media. The resultant gelatin/chitosan porous membrane exhibited a porosity of 98 % against kerosene oil. In contrast, the flowability of 7.14 (ethanol), 5.00 (distilled water) and 0.53 (ethylene glycol) mL/min has been recorded against the mentioned liquids. The membrane efficiently purified the local canal water to permissible limits. Such membranes have been qualified for potential applications in water purification systems.

Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Background: Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. Methods: In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Results: Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Conclusion: Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.

Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions.

OBJECTIVES: Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID. PATIENTS AND METHODS: Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. RESULTS: MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID. CONCLUSIONS: Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.

Classification of Health Information Technology Safety Events in a Pediatric Tertiary Care Hospital.

OBJECTIVE: State agencies have developed reporting systems of safety events that include events related to health information technology (HIT). These data come from hospital reporting systems where staff submit safety reports and nurses, in the role of safety managers, review, and code events. Safety managers may have varying degrees of experience with identifying events related to HIT. Our objective was to review events potentially involving HIT and compare those with what was reported to the state. METHODS: We performed a structured review of 1 year of safety events from an academic pediatric healthcare system. We reviewed the free-text description of each event and applied a classification scheme derived from the AHRQ Health IT Hazard Manager and compared the results with events reported to the state as involving HIT. RESULTS: Of 33,218 safety events for a 1-year period, 1247 included key words related to HIT and/or were indicated by safety managers as involving HIT. Of the 1247 events, the structured review identified 769 as involving HIT. In comparison, safety managers only identified 194 of the 769 events (25%) as involving HIT. Most events, 353 (46%), not identified by safety managers were documentation issues. Of the 1247 events, the structured review identified 478 as not involving HIT while safety managers identified and reported 81 of these 478 events (17%) as involving HIT. CONCLUSIONS: The current process of reporting safety events lacks standardization in identifying health technology contributions to safety events, which may minimize the effectiveness of safety initiatives.

A comparative study to assess thoracic kyphotic index in adults with and without mechanical neck pain.

OBJECTIVE: To assess thoracic kyphotic index in adults, and to find out the correlation between Neck Disability Index and Thoracic Kyphotic Index. METHODS: The analytical cross-sectional study was conducted from October 2020 to January 2021 at the Shifa Tameer-e-Millat University, Islamabad, Pakistan, and comprised adults aged 18-35 years. Those with neck pain formed group A, while those without neck pain formed group B. The Numeric Pain Rating Scale and the Neck Disability Index were used to measure mechanical neck pain, while the Thoracic Kyphotic Index value was measured using a flexicurve ruler. Data was analyzed using SPSS 24. RESULTS: Of the 74 subjects, 37(50%) were in each of the two groups. There were 19 (51.40%) females and 18(48.60%) males in group A, while in group B there were 18(48.60%) females and 19(51.40%) males. The overall mean age of the sample was 23.35±3.31 years. Group A showed higher Thoracic Kyphotic Index value than group B (p=0.0001). The Neck Disability Index showed negative weak (r=-0.18, p=0.28) correlation with Thoracic Kyphotic Index in group B and moderate positive correlation (r=0.33, p=0.04) in group A. CONCLUSIONS: Higher Thoracic Kyphotic Index value was found among adults with mechanical neck pain compared to healthy adults.

Length of Stay and Barriers to Discharge for Technology-Dependent Children During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVE: During the coronavirus disease 2019 pandemic, technology-dependent children are at risk of encountering barriers to hospital discharge because of limits to in-home services. Transition difficulties could increase length of stay (LOS). With this study, we aim to (1) evaluate change in LOS and (2) describe barriers to hospital discharge between prepandemic and early pandemic periods for technology-dependent children. METHODS: A retrospective chart review of technology-dependent children discharged from an acute and specialty pediatric hospital within a single urban area between January 1 and May 28, 2020 was conducted. Technology dependence was defined by using a validated complex chronic condition coding system. Patients discharged prepandemic and during the pandemic were compared. Outcomes included LOS and the number and type of discharge barriers (a factor not related to a medical condition that delays discharge). Multivariate regression modeling and parametric and nonparametric analysis were used to compare cohorts. RESULTS: Prepandemic, 163 patients were discharged, and 119 were discharged during the early stages of the pandemic. The most common technology dependence was a feeding tube. The unadjusted median LOS was 7 days in both groups. After adjusting for patient-level factors, discharge during the pandemic resulted in a 32.2% longer LOS (confidence interval 2.1%-71.2%). The number of discharge barriers was high but unchanged between cohorts. Lack of a trained caregiver was more frequent during the pandemic (P = .03). CONCLUSIONS: Barriers to discharge were frequent for both cohorts. Discharge during the pandemic was associated with longer LOS. It was more difficult to identify a trained caregiver during the pandemic.

An Alternative Airway Intervention to Preserve the Surgical Field in Oral and Maxillofacial Surgery.

Background/need. Office-based sedation has become increasingly commonplace in dental offices in recent years, allowing for practitioners to provide broader scope of care for their patients. Maintaining high standards of safety is of utmost importance when sedation is utilized in the office-based setting, especially for patients deemed at a higher-risk for intraoperative airway obstruction. This demographic includes but is not limited to individuals with a medical history significant for obstructive sleep apnea, chronic obstructive pulmonary disease, and morbid obesity. Presently, a wide variety of airway devices exist for use in the event of airway obstruction. However, in the context of oral and maxillofacial surgery, placement of these devices can encroach upon the surgical field, extending the perioperative period and putting the patient at greater long-term risk for maintaining adequate oxygenation. Methodology. The authors describe a preliminary technique trialed in our offices which utilizes a size 5.0 endotracheal tube (5OET) as an adjunct supraglottic airway to help mitigate the issue of oxygen saturation maintenance, as well as unimpeded access to the oral cavity. Implementation of the device requires identifying appropriate candidates during preoperative screening and placing the device through the nare and securing it above the glottis. Device Description. The 'tube kit' is comprised of a standard size straight 5.0 cuffed oral ETT, a 5-mL syringe for inflation of the cuff post insertion, lubricant, flex extension tubing, end tidal sampling line for capnography, tape for securement of the 5OET, and an anesthesia breathing circuit. Optional equipment pieces include an elbow connecter and a foam piece for comfort. Results/Current Status. Preliminary results have demonstrated oxygen saturations maintained above 98% when the 5OET is placed preoperatively. Continued use of the trial device will inform the development of a tube by our clinicians, and its efficacy will be studied in our offices. The next steps will be to start developing a pilot cuff that will be submitted for patent approval after its use in IRB-approved clinical studies.

Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children.

OBJECTIVE: Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse. METHODS: We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed. RESULTS: Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse." CONCLUSIONS: ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.

Breast Cancer Management Consensus By The Society of Surgeons and Surgical Oncology Society of Pakistan.

The Society of Surgeons of Pakistan and The Society of Surgical Oncology of Pakistan with factions from various major centres comprising of surgical oncology, medical and radiation oncology collaborated to reach consensus on breast cancer management guidelines and a framework of "good practice" minimum standards of care. The aim of the task force was to enhance treatment standards, which have a direct correlation with improving patient mortality and morbidity and long-term survival whilst taking into consideration economic limitations of access to leading centers of excellence as well as minimum expertise required in health care. These multidisciplinary guidelines, whilst not exhaustive, aim to provide an algorithm of care for breast cancer patients at tertiary care centres and district level hospitals to provide most appropriate treatment.

Papillary Carcinoma of Breast: Clinicopathological Characteristics, Management, and Survival.

Objective: To study clinicopathological features, treatment strategies, and prognosis of papillary carcinoma of breast. Material and Methods. Data from 58 patients were retrospectively reviewed from January 2010 to December 2016. Four types of papillary carcinoma (on final resected specimen) were included, i.e., invasive papillary carcinoma (IPC), intracystic (encapsulated) papillary carcinoma (EPC), solid papillary carcinoma (SPC), and papillary DCIS (ductal carcinoma in situ). Various features of the four types were observed and compared. Results: Of the 58 patients, 8 were males (13.7%). The mean age at presentation was 61 years; the mean tumor size was 33 mm. The frequency of each histological type was as follows: IPC (n = 22/38%), EPC (n = 22/38%), SPC (n = 12/20.6%), and papillary DCIS (n = 2/3.4%). Only two patients were ER negative (both IPC). HER-2 Neu was positive in 3 patients only, out of which 2 died of progressive disease (one EPC and one IPC). LN metastasis was present in 3 (5%) patients (one in each of 1st three types) and only one died of bone metastasis that was also Her-2Neu positive. All patients underwent upfront surgery except two patients who had synchronous IDC on the contralateral side. Breast conservation surgery (BCS) was performed in 34 (58.6%) and mastectomy in 22 (37.9%) patients. 13 patients did not undergo invasive axillary staging; the rest of 43 (74%) patients did (32 sentinel biopsy and 11 axillary dissection). Chemotherapy was given to 18 patients (31%), mostly to IPC (n = 12). Only 2 patients had bone metastasis (one was IPC and one EPC). Cancer-related death was observed in 3 patients. For all groups combined, 5-year OS was 98% and DFS was 92%. Conclusion: Overall, papillary carcinoma of the breast has an excellent prognosis, even though less intense treatment modalities were used. It is still difficult to define the optimum management and avoid overtreatment, given the limited data in the literature.

Cost-utility of cytisine for smoking cessation over and above behavioural support in people with newly diagnosed pulmonary tuberculosis: an economic evaluation of a multicentre randomised controlled trial.

OBJECTIVES: To assess the cost-effectiveness of cytisine over and above brief behavioural support (BS) for smoking cessation among patients who are newly diagnosed with pulmonary tuberculosis (TB) in low-income and middle-income countries. DESIGN: An incremental cost-utility analysis was undertaken alongside a 12-month, double-blind, two-arm, individually randomised controlled trial from a public/voluntary healthcare sector perspective with the primary endpoint at 6 months post randomisation. SETTING: Seventeen subdistrict hospitals in Bangladesh and 15 secondary care hospitals in Pakistan. PARTICIPANTS: Adults (aged ≥18 years in Bangladesh and ≥15 years in Pakistan) with pulmonary TB diagnosed within the last 4 weeks who smoked tobacco daily (n=2472). INTERVENTIONS: Two brief BS sessions with a trained TB health worker were offered to all participants. Participants in the intervention arm (n=1239) were given cytisine (25-day course) while those in the control arm (n=1233) were given placebo. No significant difference was found between arms in 6-month abstinence. PRIMARY AND SECONDARY OUTCOME MEASURES: Costs of cytisine and BS sessions were estimated based on research team records. TB treatment costs were estimated based on TB registry records. Additional smoking cessation and healthcare costs and EQ-5D-5L data were collected at baseline, 6-month and 12-month follow-ups. Costs were presented in purchasing power parity (PPP) adjusted US dollars (US$). Quality-adjusted life years (QALYs) were derived from the EQ-5D-5L. Incremental total costs and incremental QALYs were estimated using regressions adjusting for respective baseline values and other baseline covariates. Uncertainty was assessed using bootstrapping. RESULTS: Mean total costs were PPP US$57.74 (95% CI 49.40 to 83.36) higher in the cytisine arm than in the placebo arm while the mean QALYs were -0.001 (95% CI -0.004 to 0.002) lower over 6 months. The cytisine arm was dominated by the placebo arm. CONCLUSIONS: Cytisine plus BS for smoking cessation among patients with TB was not cost-effective compared with placebo plus BS. TRIAL REGISTRATION NUMBER: ISRCTN43811467.

Correlation of Breast Density Grade on Mammogram With Diagnosed Breast Cancer: A Retrospective Cross-Sectional Study.

Objective The objective of this study is to determine any association between mammographic density (MD) and breast cancer in Pakistani population. The study will also investigate relationship between mammographic breast density, clinical characteristics, and molecular tumor markers of the disease. Methods A retrospective review of data was carried out from January 2020 to December 2020 with stage 0-3 patients with histologically proven breast cancer included in the study. Mammograms were reviewed and density grade was recorded in accordance with "Breast Imaging Reporting and Data System (BIRADS)" guidelines. Patient age, tumor, and receptor characteristics were studied and their association with mammographic density was investigated by using chi-square test. P-value ≤0.05 was considered statistically significant. Results A total of 361 patients were included with a mean age of 46 years. The frequencies of BIRAD categories were as follows: category A: 8.9%, category B: 43.2%, category C: 33.5%, and category D: 14.4%. Cumulative frequency of categories B and C was 76.7%. There is a statistically significant p-value ≤0.05 association observed between age, estrogen receptors (ER) status, and T-stage versus MD. Also, majority of our patients were in T-stage category 2 or 3, which can easily be picked on mammogram. Conclusion Most of the breast cancer patients in our population had a mammographic density of B or C, indicating that breast cancer is more common in dense breasts. Strong significant association of mammographic density with age, ER status, and tumor stage was found in our population. Future studies need to address and confirm MD and its association with subtypes and aggressiveness of breast cancer.

Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study.

BACKGROUND: Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes. METHODS: We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis. RESULTS: Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14-20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes. CONCLUSIONS: System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale.