Fungal behavior and recent developments in biopulping technology.

Biological pretreatment of wood chips by fungi is a well-known approach prior to mechanical- or chemical pulp production. For this biological approach, a limited number of white-rot fungi with an ability to colonize and selectively degrade lignin are used to pretreat wood chips allowing the remaining cellulose to be processed for further applications. Biopulping is an environmentally friendly technology that can reduce the energy consumption of traditional pulping processes. Fungal pretreatment also reduces the pitch content in the wood chips and improves the pulp quality in terms of brightness, strength, and bleachability. The bleached biopulps are easier to refine compared to pulps produced by conventional methodology. In the last decades, biopulping has been scaled up with pilot trials towards industrial level, with optimization of several intermediate steps and improvement of economic feasibility. Nevertheless, fundamental knowledge on the biochemical mechanisms involved in biopulping is still lacking. Overall, biopulping technology has advanced rapidly during recent decades and pilot mill trials have been implemented. The use of fungi as pretreatment for pulp production is in line with modern circular economy strategies and can be implemented in existing production plants. In this review, we discuss some recent advances in biopulping technology, which can improve mechanical-, chemical-, and organosolv pulping processes along with their mechanisms.

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.

Resilience and its associated factors in brain tumor patients in Karachi, Pakistan: An analytical cross-sectional study.

OBJECTIVES: This study assessed resilience in brain tumor patients at a tertiary care hospital in Pakistan (a lower middle-income country; LMIC) and explored its relationship with patients' sociodemographic factors, clinical characteristics, social support, and mental health. METHODS: A cross-sectional survey was conducted amongst adult (≥18 years) patients with brain tumor at the Aga Khan University Hospital, Pakistan. Resilience was assessed by Wagnild and Young's Resilience Scale, and patients' psychosocial characteristics by the Hospital Anxiety and Depression Scale and the Enriched Social Support Instrument. RESULTS: A total of 250 patients were included (mean age: 44 years; 68% males), with majority (97.6%) having high social support and only 4.4% and 2% having symptomatic depression and anxiety, respectively. On multivariable linear regression adjusted for covariates, lower resilience was associated with not being involved in household decision-making (Adjusted Beta Coefficient: 4.58 [95% Confidence Interval:-7.59, -1.56]), not currently working (-2.80 [-4.61, -0.99]), undergoing multiple neurosurgical interventions such as tumor biopsies or resections (-8.64 [-13.11, -4.16]), receiving chemotherapy (-5.17 [-9.51, -0.83]) or combination adjuvant therapy (-2.91 [-5.14, -0.67]), low social support (-7.77 [-13.73, 1.81]), mild depression (-13.00 [-17.00,-8.99]) or symptomatic depression (-19.79 [-24.69, -14.89]), and mild anxiety (-4.24 [-7.98, -0.50]). CONCLUSION: Our study highlights the function of familial/household role and working status in mediating resilience, and demonstrates the well-known protective effect of resilience for mental health in brain tumor patients in Pakistan, a South-Asian LMIC. These findings are of clinical relevance with regards to the development of culture-specific evidence-based resilience-building interventions that may help patients with brain tumors to cope with the psychological distress of cancer.

Endovascular coil embolization of ruptured and unruptured intracranial aneurysms: review of a 15 year single center experience in Pakistan.

OBJECTIVE: To assess the outcome of endovascular treatment of intracranial aneurysm over 15 years. METHODS: The retrospective study was conducted at the at Radiology Department of Aga Khan University Hospital, Karachi, and comprised medical records from April 2003 to April 2018 of patients who received endovascular treatment for intracranial aneurysm. Multiple variables reviewed included demographics, clinical presentation, aneurysm morphology, technique used, technique outcome and clinical outcome. Data was analysed using SPSS 22. RESULTS: Of the 242 patients, 111(45.8%) were males and 131(54.1%) were female. The overall mean age was 46.3+/-13.543 years (range: 9-78years). Aneurysm size was <5mm in 95(40.4%) patients, 5-10mm in 98(41.7%) and >10mm in 42(17.9%) patients. Aneurysms were located in the anterior communicating artery in 93(38.4%) patients, internal carotid artery 48(19.8%) patients and posterior communicating artery 26(10.7%) patients. Patients with higher initial Hess and Hunt grade were more likely to have higher modified Rankin scale score after treatment (p=0.001). Overall, 222(91.7%) patients were treated successfully. Complications were noted in 37(15.2%) patients and 10(4.0%) patients died. CONCLUSIONS: No correlation was found between Hess and Hunt grades and aneurysm severity based on aneurysm size, neck and ruptured/unruptured cases.

Anaesthetic management of patients undergoing deep brain simulation: A retrospective review of 8 cases from a tertiary care center of Pakistan.

OBJECTIVES: To review anaesthesia related outcome, perioperative complications and overall length of stay (LOS) in hospital for patients who had deep brain stimulation (DBS). METHODS: The study was retrospective review of patients medical records diagnosed with Parkinson disease (PD) and underwent DBS at The Aga Khan University Hospital, Karachi from 2017-2019. Data was reviewed from file notes and patient chart and recorded on predesigned Performa. Frequency and percentages were used to present the data. RESULTS: All patients were anaesthetized using Sleep-Awake-Sleep technique (SAS). Dexmedetomidine was mainly used for conscious sedation. Bispectral index monitor (BIS) was used to monitor the depth of sedation, and kept between 70-85 during sedative phase. All patients had successful intraoperative neurological monitoring, stimulation, and placement of electrodes. Total duration of anesthesia varied significantly in between the patients. Maximum duration was 600 minutes. None of our patient had any intraoperative event related to anaesthetic management. Overall five patients had some adverse events during ward stay. Mean LOS in hospital was four days. CONCLUSION: Anaesthetic management of DBS is well-tolerated. It requires dedicated team. The SAS technique is excellent for intraoperative neurophysiological monitoring. Careful selection of sedative agents and monitoring depth of anaesthesia using BIS would be beneficial in terms of improving related outcomes.

Natural decomposition of hornbeam wood decayed by the white rot fungus Trametes versicolor.

The impacts of white-rot fungi on altering wood chemistry have been studied mostly in vitro. However, in vivo approaches may enable better assessment of the nature of interactions between saprotrophic fungi and host tree in nature. Hence, decayed and sound wood samples were collected from a naturally infected tree (Carpinus betulus L.). Fruiting bodies of the white rot fungus Trametes versicolor grown on the same tree were identified using rDNA ITS sequencing. Chemical compositions (cellulose and lignin) of both sound and infected wood were studied. FT-IR spectroscopy was used to collect spectra of decayed and un-decayed wood samples. The results of chemical compositions indicated that T. versicolor reduced cellulose and lignin in similar quantities. Fungal activities in decayed wood causes serious decline in pH content. The amount of alcohol-benzene soluble extractives was severely decreased, while a remarkable increase was found in 1% sodium hydroxide soluble and hot water extractive contents in the decayed wood samples, respectively. FT-IR analyses demonstrated that T. versicolor causes simultaneous white rot in the hornbeam tree in vivo which is in line with in vitro experiments.

Confusing presentation of chaetomium brain abscess.

We put forth the case of a young immunocompetent female who presented with fever and left basal ganglia bleed secondary to vasculitis. After 2 weeks of prednisolone therapy, she continued to deteriorate. MRI scan revealed enhancement of previous hematoma, pus was aspirated surgically and fungal culture grew Chaetomium.

Craniocerebral injuries in war against terrorism --- a contemporary series from Pakistan.

OBJECTIVE: Terrorism-related bomb attacks on civilian population have increased dramatically over the last decade. Craniocerebral injuries secondary to improvised explosive devices have not been widely reported in the context of unarmored civilians. This series intends to report the spectrum of these injuries secondary to suicidal and implanted bombs as encountered at the Aga Khan University Hospital, Pakistan (AKUH). Further, a few pertinent management guidelines have also been discussed. METHODS: The hospital database and clinical coding during a 5-year period were examined for head injuries secondary to terrorism-associated blasts. In addition to patient demographics, data analysis for our series included initial Glasgow Coma Scale, presenting neurological complaints, associated non-neurological injuries, management (conservative or operative) to associated complications, and discharge neurological status. RESULTS: A total of 16 patients were included in this series. Among them 9 were victims of suicidal blasts while 7 were exposed to implanted devices. The patients presented with diverse patterns of injury secondary to a variety of shrapnel. A follow-up record was available for 12 of the 16 patients (mean follow-up: 7.8 months), with most patients having no active complaints. CONCLUSION: The results of this series show that civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns, which often differ from the neurological injuries incurred by military personnel in similar situations, and thereby often require individualized care.

Tailoring of neurosurgical practice during COVID-19 in a developing country: Insights gained and a way forward.

Background: The coronavirus disease-19 pandemic has aggravated the already neglected neurosurgical specialty in developing countries with a mounting shortage of specialists, long queues of operative patients, and a lack of adequate critical care units. Methods: We have reviewed the innovative strategies adopted for maintaining an optimal surgical practice while ensuring team safety at the Aga Khan University Hospital, Karachi Pakistan. Results: There is already a scarcity of resources in developing countries. The international guidelines had to be tailored to the context of the developing world. A multimodal strategy that focused on infection control, continuum of care, and the well-being of staff was adopted at Aga Khan University. Patients were screened and seen either in person or through telemedicine, depending on the severity of the disease. All educational activities for residents were shifted online, and this helped in preventing overcrowding. Conclusion: Optimal surgical practice while ensuring team safety can be achieved through a multimodal strategy focusing on infection control, continuum of care, and the well-being of staff.

Factors affecting well-being in brain tumor patients: An LMIC perspective.

Introduction: Brain tumor is a devastating and often fatal diagnosis; quality of life and patient well-being are important goals of treatment. This study addresses the gap in culture-specific literature exploring the needs and coping strategies of brain tumor patients within an LMIC setting. Methodology: A qualitative approach was undertaken using an exploratory descriptive study design. In-depth interviews were conducted to capture the perspective of 250 brain tumor patients at a private tertiary center followed by extensive content analysis to identify major themes and sub-themes across responses. Results: The analysis identified three major themes: (i) Factors affecting the lives of brain tumor survivors (BTSs) and their impact (ii) What works to improve QoL according to the survivors' perspectives, and (iii) Coping tactics & fostering healthy relationships. The need for financial navigation strategies improved patient-physician relationships, and reinforcing positive coping strategies were emphasized. Conclusion: In our population, family support and spiritual connection played an important role in helping patients mitigate the psychosocial burden of illness. However, financial concerns were pervasive and need to be addressed for better overall well-being.

Psychosocial factors influencing quality of life in patients with primary brain tumors in Pakistan: an analytical cross-sectional study.

OBJECTIVE: Despite quality of life (QoL) being recognized as an important outcome in neuro-oncology, there is a lack of research from Pakistan where sociocultural differences may influence QoL. This study aimed to measure the QoL in patients with primary brain tumors (PBTs) and assess its association with mental health outcomes and social support. RESULTS: Our study included a total of 250 patients, with a median age of 42 years (range 33-54 years). The commonest brain tumors were glioma (46.8%) and meningioma (21.2). The mean global QoL of the sample was 75.73 ± 14.9. The majority of patients had high social support (97.6%) and were not depressed (90%) or anxious (91.6%). On multivariable linear regression, global QoL was inversely associated with no or low income (beta coefficients: -8.75 to -11.84), having hypertension (-5.53), currently using a urine catheter (-13.55), having low social support (-28.16) suffering from mild (-15.31) or symptomatic (-23.84) depression, or mild anxiety (-13.22).

Developmental delay in a patient with single cerebral varix.

Background: Cerebral varices are intracranial venous anomalies that are characterized as thin-walled vessels, with a single layer of endothelium lining it and a thin lamina or fibrous connective tissue surrounding it. These varices are usually associated with vascular abnormalities such as arteriovenous malformations or developmental venous anomalies, but may rarely be found as isolated lesions as well. Diagnosis of these isolated lesions on imaging is a challenge, because it is a rare entity and can mimic a space occupying lesion in the brain. The patients with isolated cerebral varix can present with neurological symptoms; however, majority are asymptomatic with the diagnosis made incidentally. Case Description: The aim of this study is to report a case of a 21-month-old boy who was diagnosed with an isolated cerebral varix and had presented with delayed milestones in addition to seizures. His MRI scans showed a solid-cum-cystic lesion with contrast enhancing walls that was excised through craniotomy. Postoperatively, he regained his milestones. Conclusion: The patients with isolated cerebral varix can present with neurological symptoms; however, majority are asymptomatic with the diagnosis made incidentally. These patients have a low risk of bleeding and are treated conservatively, with surgical intervention indicated only in symptomatic patients.

Intracerebral migration of stray bullet leading to sudden and fatal worsening.

Gunshot wounds to the cranium are one of the leading cause of death and disability in young adults. Stray bullets are also being increasingly seen in clinical setting. We report a case of a 14-year-old boy who sustained a stray bullet to the cranium during election festivities. He arrived at the health care facility institution nearly 24 hours after the event in good neurological condition. He remained neurologically stable for about 8 hours after his presentation and later on deteriorated due to intracranial bullet migration. This required immediate bifrontal decompressive craniotomy along with right frontal lobectomy. However, the patient could not survive.

Current Strategies for the Production of Sustainable Biopolymer Composites.

Rapid global population growth has led to an exponential increase in the use of disposable materials with a short life span that accumulate in landfills. The use of non-biodegradable materials causes severe damage to the environment worldwide. Polymers derived from agricultural residues, wood, or other fiber crops are fully biodegradable, creating the potential to be part of a sustainable circular economy. Ideally, natural fibers, such as the extremely strong fibers from hemp, can be combined with matrix materials such as the core or hurd from hemp or kenaf to produce a completely renewable biomaterial. However, these materials cannot always meet all of the performance attributes required, necessitating the creation of blends of petroleum-based and renewable material-based composites. This article reviews composites made from natural and biodegradable polymers, as well as the challenges encountered in their production and use.

Characterizing Fungal Decay of Beech Wood: Potential for Biotechnological Applications.

The biotechnological potential of nine decay fungi collected from stored beech logs at a pulp and paper factory yard in Northern Iran was investigated. Beech blocks exposed to the fungi in a laboratory decay test were used to study changes in cell wall chemistry using both wet chemistry and spectroscopic methods. Pleurotus ostreatus, P. pulmonarius, and Lentinus sajor-caju caused greater lignin breakdown compared to other white-rot fungi, which led to a 28% reduction in refining energy. Trametesversicolor caused the greatest glucan loss, while P. ostreatus and L. sajor-caju were associated with the lowest losses of this sugar. Fourier transform infrared spectroscopy (FTIR) analyses indicated that white-rot fungi caused greater lignin degradation in the cell walls via the oxidation aromatic rings, confirming the chemical analysis. The rate of cellulose and lignin degradation by the T.versicolor and Pleurotus species was high compared to the other decay fungi analyzed in this study. Based on the above information, we propose that, among the fungi tested, P. ostreatus (27.42% lignin loss and 1.58% cellulose loss) and L. sajor-caju (29.92% lignin loss and 5.95% cellulose loss) have the greatest potential for biopulping.

Translation and validation of the Urdu version of the European organization for research and treatment of cancer core quality of life questionnaire (EORTC QLQ-C30) and brain module (QLQ-BN20) in primary brain tumor patients.

INTRODUCTION: This study translated and validated the Urdu version of the European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire (EORTC QLQ-C30) and Brain Module (QLQ-BN20) amongst patients with primary brain tumors (PBT) in Pakistan, and assessed the correlation of QoL with resilience, depression, and anxiety. METHODS: Translation of the EORTC QLQ-C30 and QLQ-BN20 was performed as per EORTC guidelines. A survey comprising of Urdu translations of EORTC QLQ-C30, QLQ-BN20, Wagnild and Young Resilience Scale (RS-14) and Hospital Anxiety and Depression Scale was administered to patients with PBT at a tertiary care hospital in Pakistan. Reliability (via Cronbach alpha), content validity index (CVI) scores, construct validity, and inter-scale correlations were assessed. RESULTS: Our sample consisted of 250 patients with PBT, most commonly glioma (46.8%) and meningioma (21.2%). All patients were able to understand the Urdu translations. The Cronbach alphas for the QLQ-C30 and the QLQ-BN20 were 0.860 and 0.880, respectively. The CVI scores for clarity and relevance were high for both the EORTC QLQ-C30 (0.98 and 0.96, respectively) and the QLQ-BN20 tool (0.81 and 0.95, respectively). The global QoL domain (EORTC QLQ-C30) showed significant positive correlations with resilience (r = 0.422), and significant negative correlations with depression (r = - 0.541) and anxiety (r = - 0.502). Strong inter-scale correlations were observed between physical functioning and insomnia (r = - 0.690) and role functioning and insomnia (r = - 0.641). CONCLUSION: Our study confirms the Urdu versions of the EORTC QLQ-C30 and QLQ-BN20 as valid clinical tools for the measurement of QoL in primary brain tumors patients within the cultural and socioeconomic context of Pakistan.

Quality of life (QoL) is an important facet of well-being for patients with primary brain tumors (PBTs), as these individuals face significant distress during the course of their illness and treatment. It is important to have valid and reliable tools to accurately measure the QoL of patients with PBTs. The EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) and its brain tumor-specific module EORTC QLQ-BN20 (EORTC QLQ-Brain Neoplasms 20) are exactly that.However, the use of the EORTC QLQ-C30 and QLQ-BN20 is limited in Pakistan, where the national language is Urdu, and the majority of patients are of low socioeconomic backgrounds. Since no Urdu translations of the EORTC QLQ-C30 and QLQ-BN20 exist, we aimed to translate and validate these tools to enable their applicability in Pakistan.The Urdu versions of the EORTC QLQ-C30 and QLQ-BN20 demonstrated good validity amongst patients with PBTs. Thus, our study confirms the EORTC QLQ-C30 and QLQ-BN20 as valuable clinical tools for the measurement of QoL in primary brain tumors patients within the linguistic, cultural and socioeconomic context of Pakistan.

Craniocerebral gunshot injuries in preschoolers.

INTRODUCTION: Gunshot wounds (GSW) to the head are the most lethal form of trauma; unfortunately, the frequency of children being involved in such form of trauma is increasing at an alarming rate worldwide. We present our experience with four children from 2 to 3 years of age with craniocerebral GSW admitted to the neurosurgery service at a tertiary care hospital. METHODS: For this study, four children, 2 to 3 years old, injured solely from bullet injuries to the head were selected. Their history, arrival Glasgow Coma Scale (GCS), clinical presentation at the time of arrival in ER, radiological findings, management, and follow-up reviewed. RESULTS: Out of four children, only one did not survive. The bullet entrance wound was in the parietal region in robbery-related incidences, and, in three cases, the injury was bihemispheric. The time taken to reach the emergency department was less than 2 h for all patients except one. Of four patients, three presented with GCS between 3 and 5 while 1 presented with GCS well above ten. CONCLUSION: Our results show that even in children presenting with low GCS<5, an early act of aggressive surgical intervention can prove to be a life-saving measure.

Comparison of the Decay Behavior of Two White-Rot Fungi in Relation to Wood Type and Exposure Conditions.

Fungal wood decay strategies are influenced by several factors, such as wood species, moisture content, and temperature. This study aims to evaluate wood degradation characteristics of spruce, beech, and oak after exposure to the white-rot fungi Pleurotusostreatus and Trametesversicolor. Both fungi caused high mass losses in beech wood, while spruce and oak wood were more resistant to decay. The moisture content values of the decayed wood correlated with the mass losses for all three wood species and incubation periods. Combined microscopic and chemical studies indicated that the two fungi differed in their decay behavior. While T. versicolor produced a decay pattern (cell wall erosion) typical of white-rot fungi in all wood species, P. ostreatus caused cell wall erosion in spruce and beech and soft-rot type I (cavity formation) decay in oak wood. These observations suggest that P. ostreatus may have the capacity to produce a wider range of enzymes/radicals triggered by the chemical composition of wood cell walls and/or local compositional variability within the cell wall.

Pediatric Brainstem Gliomas: An Institutional Experience.

OBJECTIVE: The aim of this study was to analyze the clinical profiles and outcomes of pediatric brainstem gliomas treated at our institute. METHODOLOGY: We reviewed the files of 18 pediatric age group patients diagnosed with brainstem glioma at our institution. The following variables were recorded: age, sex, duration of symptoms, date of diagnosis, main clinical symptoms, Karnofsky performance status score, magnetic resonance imaging findings, histopathology findings, details of the treatment given, disease progression, and date of mortality/last follow-up. This data were then transferred to SPSS version 23 which was used for further analysis. RESULTS: The mean age of our cohort was 8.6 years (range 3-15). There were 11 (61.1%) males and 7 (38.9%) females. There were 16 (88.9%) patients with diffuse intrinsic pontine gliomas (DIPGs), 1 (5.6%) patients with exophytic medullary gliomas, and 1 (5.6%) patient with midbrain/tectal glioma. Mean overall survival (OS) was 9.7 months. Mean progression-free survival (PFS) was 6.3 months. All patients with DIPG eventually passed away from their disease. Patients with DIPG who received radiotherapy had a longer OS and PFS than those who did not (9.8 and 6 months vs. 3.4 and 2.4 months). Diagnostic latency >1 month was found to have a statistically significant longer progression-free interval. CONCLUSION: DIPGs in the pediatric population have a poor prognosis. Radiotherapy serves to increase survival time but is not curative.