Paediatric choroid plexus carcinoma: a retrospective case series from Karachi.

The objective of this study is to report clinical, radiological, and histopathological characteristics of three paediatric patients diagnosed as Choroid plexus carcinoma seen at our hospital, between 2015 and 2020. Three patients were diagnosed with choroid plexus carcinomas between 2015 and 2018. The mean age at diagnosis was 1.3 years (range 8 months to 1.5 years). All the three patients had subtotal resection and received adjuvant chemotherapy. One patient also received adjuvant radiotherapy. Despite these treatment measures, residual disease was noted in all three patients and two patients were subsequently treated on palliative care grounds. The average duration of follow-up after the first surgery for all three patients was approximately 33 months. Attaining satisfactory outcome in patients with CPC is challenging. Our case series reflects the difficulty in achieving gross total resection and ensuring that the disease does not recur.

Does CPT Modifier 22 Appropriately Reflect a Difficult Pancreaticoduodenectomy? Retrospective Analysis of Operative Outcomes and Cost.

BACKGROUND: CPT coding allows addition of a 2-digit modifier code to denote particularly difficult procedures necessitating additional reimbursement, called the modifier 22. The use of modifier 22 in relation to pancreatic surgery and outcomes, specifically pancreaticoduodenectomy (PD), has not been explored. STUDY DESIGN: All PDs performed from 2010 to 2019 at a quaternary healthcare system were analyzed for differences in preoperative characteristics, outcomes, and cost based on the use of modifier 22. Adjusted logistic regression analysis was used to identify factors predictive of modifier 22 use. RESULTS: A total of 1,284 patients underwent PD between 2010 and 2019; 1,173 with complete data were included, of which 320 (27.3%) were coded with modifier 22. Patients coded with modifier 22 demonstrated a significantly longer duration of surgery (365.9 ± 168.4 vs 227 ± 97.1; p < 0.001). They also incurred significantly higher cost of index admission ($37,446 ± 34,187 vs $28,279 ± 27,980; p = 0.002). An adjusted multivariable analysis (specifically adjusted for surgeon variation) revealed duration of surgery (p < 0.001), neoadjuvant chemotherapy (p = 0.039), class II obesity (p = 0.019), and chronic pancreatitis (p = 0.005) to be predictive of modifier 22 use. CONCLUSIONS: Despite the subjective nature of this CPT modifier, modifier 22 is an appropriate marker of intraoperative difficulty. Preoperative and intraoperative characteristics that lead to its addition may be used to further delineate difficult PDs.

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

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

Pediatric intracranial calcified arteriovenous malformation: A case report.

BACKGROUND: Brain arteriovenous malformations (AVMs) are intracranial lesions that consist of a complex tangle of abnormal blood vessels. They can occasionally become hard and calcified. This may render these lesions difficult to resect and lead to neurological complications. There are very few reported cases of calcified brain AVMs in the literature. CASE DESCRIPTION: We report the case of an 11-year-old patient who presented with headaches and seizures exacerbated in the past 3 months. Preoperative imaging confirmed a large, right parasagittal AVM, with significant internal calcifications seen on the computed tomography angiogram. We performed a successful microsurgical resection of the calcified AVM and confirmed the diagnosis on histopathological analysis. CONCLUSION: Dense internal calcifications within AVMs are a clinical rarity and can be challenging cases for microsurgical resection.

Counting the cost: financial implications of complications following pancreaticoduodenectomy.

BACKGROUND: Morbidity after pancreaticoduodenectomy (PD) has been reported to be about 30-53%. These complications can double hospital costs. We sought to explore the financial implications of complications after PD in a large institutional database. METHODS: A retrospective analysis of patients undergoing PD from 2010-2017 was performed. Costs for index hospitalization were divided into categories: operating room, postoperative ward, radiology and interventional radiology. Complications were categorized according to the Clavien-Dindo classification. Univariable and mutivariable analysis were performed. RESULTS: Median cost of index admission for 997 patients who underwent PD was $23,704 (range $10,988-$528,531). Patients with major complications incurred significantly greater median costs compared to those without ($40,005 vs $21,306, p < 0.001). Patients with postoperative pancreatic fistula (POPF) grade A, B and C had progressively increasing costs ($32,164, $50,264 and $102,013, p < 0.001). On multivariable analysis ileus/delayed gastric emptying, respiratory failure, clinically significant POPF, thromboembolic complications, reoperation, duration of surgery >240 minutes and male sex were associated with significantly increased costs. CONCLUSION: Complications after PD significantly increase hospital costs. This study identifies the major contributors towards increased cost post-PD. Initiatives that focus on prevention of complications could reduce associated costs and ease financial burden on patients and healthcare organizations.

Online Medical Education and Examinations during COVID-19: Perspectives of a Teaching Associate.

The novel coronavirus disease 2019 (COVID-19) pandemic has not only challenged global health systems but also social, economic, and educational systems. In this short communication, our focus is on its impact on medical education in Pakistan. We discuss the structure of undergraduate medical education in Pakistan; and how it has evolved in the wake of COVID-19. We describe our role as teaching associates (TAs) at the Aga Khan University (AKU); and how it has enabled us to be a part of the transition to online medical education, with a specific focus on online examinations in medical schools. Key Words: Medical education, Online examinations, COVID-19, Pandemic.

Online Medical Education and Examinations during COVID-19: Perspectives of a Teaching Associate.

The novel coronavirus disease 2019 (COVID-19) pandemic has not only challenged global health systems but also social, economic, and educational systems. In this short communication, our focus is on its impact on medical education in Pakistan. We discuss the structure of undergraduate medical education in Pakistan; and how it has evolved in the wake of COVID-19. We describe our role as teaching associates (TAs) at the Aga Khan University (AKU); and how it has enabled us to be a part of the transition to online medical education, with a specific focus on online examinations in medical schools.  Key Words: Medical education, Online examinations, COVID-19, Pandemic.

The Effects of Temperature and Prothrombotic Conditions on Cerebral Venous Sinus Thrombosis Frequency: An Institutional Experience.

OBJECTIVES: The pathogenesis of cerebral venous sinus thrombosis (CVST) is complex and involves the interplay of underlying provocative factors. Upon observing a higher frequency of CVST cases presenting to our hospital in summer, we hypothesized that CVST may be influenced by variations in climate. MATERIALS AND METHODS: A retrospective review of all patients who were diagnosed with CVST at a tertiary care hospital in Pakistan between January 2010 and December 2019 was conducted. After dividing patients into groups based on the type of risk, the frequency of CVST in these groups between four seasons (spring, summer, fall, and winter) was compared. RESULTS: A total of 256 patients diagnosed with CVST were included, of which 129 were female and 127 were male. The mean age was 41.7 ± 15.2 years. Of the total patients, 91.4% had some sort of risk factor, either systemic (162 patients) or local (72 patients), while 22 patients did not have any identifiable risk factor. The number of patients with more than one known risk factor was 93 (36.3%). Of the total number of patients, 96 (37.5%) patients had hyperhomocysteinemia, followed by 85 patients (33.2%) with a prothrombotic risk factor other than hyperhomocysteinemia and 44 (17.2%) patients with central nervous system infections. The most commonly affected sinuses were a combination of the transverse sinus and sigmoid sinus (21%), There was a statistically significant seasonal variation in CVST cases among all patients (P = 0.03) and in the systemic risk factor group (P = 0.05), with the highest number of cases occurring in the summer season. CONCLUSIONS: CVST may be influenced by seasonal changes in atmospheric temperatures and humidity, especially in patients with underlying prothrombotic risk factors.

Changes in vitamin E levels as a marker of female infertility.

OBJECTIVE: To study the impact of Vitamin E (VE) levels of follicular fluid (FF) on oocyte competence, embryo development and pregnancy outcome in patients after intra cytoplasmic sperm injection (ICSI). METHODS: It was a cross-sectional study conducted in Islamabad Clinic Serving Infertile Couples in which follicular fluid of 137 females booked for ICSI, was obtained during oocyte retrieval, centrifuged and stored for analysis. VE levels in FF were analyzed by enzyme linked immune sorbent assay. Receiver Operating Curve (ROC)was used to demarcate VE levels required for acquiring pregnancy. Generalized linear model using log binomial regression was applied to see the effect of VE on pregnancy, the effect of VE on oocyte and embryo parameters was assessed by linear regression; all p-values less than 0.05 were considered statistically significant. RESULTS: ROC suggested 5.49 (unit) as the cutoff value of VE in the pregnancy group, with 72.9% area under the curve. Ninety-one females comprised Group I with VE > 5.49, whereas forty six females formed Group II with VE < 5.49. Follicular fluid VE levels were significantly high in 39 (28.5%) females who compromised pregnancy group. Chances of pregnancy increased to 4% with an increase in VE levels (p-value 0.01). VE gave significant positive relationship with all oocyte (retrieved, mature and fertilized) parameters, cleavage of embryo till its differentiation to blastocysts (p<0.01). CONCLUSIONS: Adequate amount of VE in follicular fluid enhances the possibility of maturation of oocytes which resulted in better reproductive outcome after ICSI.

A Review of Common Endoscopic Intracranial Approaches.

With the evolution of surgical techniques, endoscopy has emerged as a suitable alternative to many instances of more invasive methods. In this review article, we aim to discuss the endoscopic advancements, procedural details, indications, and outcomes of the most commonly practiced neuroendoscopic procedures. We have also summarized the uses, techniques, and challenges of neuroendoscopy in select neurosurgical pathologies.

A Rare Case of Primary Midgut Volvulus Necessitating Extensive Bowel Resection in an Adult.

A cause of acute intestinal obstruction in adults, midgut volvulus can be categorized into two types: primary type with no identifiable underlying cause, and secondary type that occurs in the presence of a predisposing condition such as, postoperative adhesions. Primary midgut volvulus can lead to bowel ischemia and necrosis, making an extensive bowel resection imminent. A potential consequence of bowel resection is short-bowel syndrome - a failure of digestion and absorption by the intestines, leading to malnutrition and other complications. As such, we report the diagnosis and management of primary midgut volvulus - a rare entity in adults - occurring in an adult patient.

Acute Orbital Pseudomeningocele Due to Traumatic Fracture in an Infant.

Paediatric orbital trauma is uncommon, but it can be associated with significant morbidity. Traumatic pseudomeningocele is an infrequent complication of orbital trauma; it occurs due to an extradural collection of cerebrospinal fluid (CSF) that develops after a dural tear. Herein, we report a case of a seven-month-old male child who presented with eye swelling and suspicion of orbital cellulitis, along with a history of a road traffic accident. He was later diagnosed with traumatic orbital pseudomeningocele and underwent a left frontal craniotomy and duroplasty along with repair of medial orbital pseudomeningocele. Postoperatively, the child remained stable and resolution of proptosis was observed.

Management of Arachnoid Cysts: A Comprehensive Review.

Arachnoid cysts are non-neoplastic, intracranial cerebrospinal fluid (CSF)-filled spaces lined with arachnoid membranes. Large arachnoid cysts are often symptomatic because they compress surrounding structures; therefore, they must be treated surgically. As several surgical management options exist, we explore the best approach according to each major type of arachnoid cyst: middle cranial fossa cyst, suprasellar cyst, intrahemispheric cyst, and quadrigeminal cyst.