Surgical fixation of metastatic spine fractures: 6-months experience at a cancer hospital from a developing country - an audit.

OBJECTIVE: To audit the outcomes in cases of surgical fixation for metastatic spine fractures at a single centre. METHODS: The retrospective audit was conducted at the Surgical Oncology Department of the Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, and comprised data of all patients who underwent surgery for metastatic spine fractures from December 1, 2019, to May 31, 2020. The patients were followed up for three months after the surgery. Pre-surgery American Spinal Injury Association Impairment Scale grades were compared with post-operative grades for all the patients. Data was analysed using SPSS 20. RESULTS: Of the 16 patients, 12(75%) were females and 4(25%) were males, with an overall mean age of 44.0±11.9 years (range: 24-64 years). The only co-morbid was hypertension, which was present in 6(37.5%) patients. The most common primary site was breast 10(62.5%), and 12(75%) patients presented more than 12 months after the initial diagnosis. Lumbar spine was involved in 10(62.5%) cases. Pre-operative American Spinal Injury Association Impairment Scale grade was E in 8(50%) patients. Post-operatively, 14(87.5%) patients had the E grade. There was complication in 1(6.25%) case that had a post-operative wound infection. CONCLUSIONS: Surgery for spinal metastases was found to be a safe and viable option for patients with metastatic spine fractures in resource-limited countries like Pakistan.

Multifocal myxopapillary ependymoma and iatrogenic spinal cord herniation: Management options and lessons learned.

Although myxopapillary ependymoma is a fairly common tumour of the lumbosacral spine, primary multi-focal myxopapillary ependymoma is a rare variant. Drop metastasis and leptomeningeal spread in the craniospinal axis is seen more frequently in the paediatric population, although it is unusual in adults. Surgical resection of the primary lesion remains the standard treatment. As per the authors' knowledge, to-date there is only one prior case in literature reporting iatrogenic spinal cord herniation with indentation after surgery for thoracolumbar spinal tumour. Here, we are discussing an unusual case of primary multi-focal ependymoma in a 16-year-old Asian boy, with drop metastasis and lepto-meningeal disease, who developed iatrogenic spinal cord herniation after the first surgery for the primary tumour. He presented to the Shaukat Khanum Memorial Cancer Hospital & Research Centre (SKMCH & RC), Lahore, after his first surgery. He underwent the definitive corrective surgery at SKMCH & RC where he was managed further. We discuss the management options for this patient and the lessons learned along the way.

Brain herniation and subsequent complications following partial resection of high-grade glioma: A case report.

Key Clinical Message: This case highlights the need for tailored strategies to address issues like brain herniation, subdural hygroma, and cerebrospinal fluid leak, which, if not managed promptly, can lead to long-term neurological deficits. Additionally, the role of specialized facilities in delivering highly specialized care for managing such intricate cases cannot be understated. Abstract: Decompressive craniectomy-induced subdural hygroma (SDH) frequently coexists with external cerebral herniation, resulting in neurological impairments. The incidence of brain herniation through a craniectomy defect postoperatively is 25%. Brain herniation (BH), SDH, and cerebrospinal fluid leak require urgent neurosurgical management as they can lead to irreversible long-term neurological deficits. We report a case of a 42-year-old male who presented with headache and grand mal seizures. He was diagnosed with herniation of brain parenchyma through the surgical defect with a displacement of the bone flap by a heterogeneously enhancing lesion in the left parietal lobe along with SDH in the left frontoparietal region post partial resection of high-grade glioma. In this report, we discuss the pathogenesis and management strategies of brain herniation, wound infection, cerebrospinal fluid (CSF) leak, ipsilateral SDH, floating bone flap, and communicating hydrocephalus in an adult patient following partial resection of high-grade glioma. This particular case emphasizes the value of an individualized patient-centered surgical approach to minimize the risk of postoperative complications.

Engagement of Lady Health Workers for COVID-19 Home-based Care in Pakistan: An Example of Task Shifting.

In April 2021, following the Federal government's decision, an intervention was designed to execute COVID-19 home-based care training program for the LHWs in all provinces to avoid overcrowding in large hospitals so that critically ill patients can get due attention and treatment. The training curriculum was developed in local languages following guidance from NIH and WHO. Basic health units were used as the venue for training and the doctors delivered the sessions as master trainers. Around 46,000 LHWs completed the training all over Pakistan and started visiting their catchment households to identify and counsel any COVID-19 patients and families on home-based care. Their post-training impressions showed that 97% were satisfied with the content, rigour, quality of training, and that they received the most updated information on COVID-19 from reliable sources. Training of these LHWs enhanced their skills for dealing with COVID-19 patients and helped ease the pressure on a stressed and over-burdened hospitals. This intervention exemplifies task shifting to LHWs, hence addressing the issue of insufficient health workforce in the hospitals and extending public healthcare to rural communities. Key Words: COVID-19, Home-based care, Health system, Lady health workers, Pakistan.

Predictors of Survival in Patients with Metastatic Brain Tumors: Experience from a Low-to-Middle-Income Country.

Objective The interplay of static factors and their effect on metastatic brain tumor survival, especially in low-to-middle-income countries (LMICs), has been rarely studied. To audit our experience, and explore novel survival predictors, we performed a retrospective analysis of brain metastases (BM) patients at Shaukat Khanum Memorial Cancer Hospital (SKMCH), Pakistan. Materials and Methods A retrospective review was conducted of consecutive patients who presented with BM between September 2014 and September 2019 at SKMCH. Patients with incomplete records were excluded. Statistical Analysis SPSS (v.25 IBM, Armonk, New York, United States) was used to collect and analyze data via Cox-Regression and Kaplan-Meier curves. Results One-hundred patients (mean age 45.89 years) with confirmed BM were studied. Breast cancer was the commonest primary tumor. Median overall survival (OS) was 6.7 months, while the median progression-free survival (PFS) was 6 months. Age ( p = 0.001), gender ( p = 0.002), Eastern Cooperative Oncology Group ( p < 0.05), anatomical site ( p = 0.002), herniation ( p < 0.05), midline shift ( p = 0.002), treatment strategies ( p < 0.05), and postoperative complications (p < 0.05) significantly impacted OS, with significantly poor prognosis seen with extremes of age, male gender (hazard ratio [HR]: 2.0; 95% confidence interval [CI]: 1.3-3.1; p = 0.003), leptomeningeal lesions (HR: 5.7; 95% CI: 1.1-29.7; p = 0.037), and patients presenting with uncal herniation (HR: 3.5; 95% CI: 1.9-6.3; p < 0.05). Frontal lobe lesions had a significantly better OS (HR: 0.5; 95% CI: 0.2-1.0; p = 0.049) and PFS (HR: 0.08; 95% CI: 0.02-0.42; p = 0.003). Conclusion BM has grim prognoses, with comparable survival indices between developed countries and LMICs. Early identification of both primary malignancy and metastatic lesions, followed by judicious management, is likely to significantly improve survival.

A 10-Year Survival-Trend Analysis of Low-Grade Glioma and Treatment Patterns from an LMIC.

Objectives The 2021 WHO Classification of Central Nervous System Tumors taxonomy laid further stress on molecular classification and prognostication of glial tumors in comparison to histopathological grading. Research shows that low-grade gliomas (LGGs) can go through malignant differentiation and lead to severe disability and death. Data from various populations will be necessary to ascertain the exact interplay between genotypic predictors of LGG and outcomes. Materials and Methods To assess the molecular pathology for glial tumors in the Pakistani population, the Shaukat Khanum Memorial Cancer Hospital carried out a retrospective chart review of electronic health records from 2008 to 2018, with immunohistochemistry analysis findings from 2010 to 2018. Patients with a pathological diagnosis of a glioma were included. Statistical Analysis Analysis was performed using IBM SPSS Statistics Version 23 and STATA Version 16. A p -value of less than 0.05 was considered statistically significant with 95% confidence intervals reported. Results In all, 281 operable tumors were recorded. The most common procedure was a subtotal resection, and astrocytomas (64.77%) were the most common tumors. Radiation therapy and PCV (procarbazine, CCNU, and vincristine) was received by 85 patients, while radiation therapy and temozolomide were administered to 15 patients. Conclusions Isocitrate dehydrogenase (IDH) wild-type LGG had a lower survival time, while improved survival times were seen for alpha-thalassemia X-linked intellectual disability syndrome (ATRX) retained and 1p19q co-deleted LGGs. Further studies are required to gain a better understanding of lower-grade glial tumor treatment and survival in Pakistan.

Adsorptive performance of MWCNTs for simultaneous cationic and anionic dyes removal; kinetics, thermodynamics, and isotherm study.

Disposal of contaminated wastewater causes many serious problems especially when it gets mixed with the ground and seawater. It is, therefore, important to apply any remedial action to eradicate dangerous pollutants from the aqueous effluents and to avoid exposure of this wastewater to aquatic life. The research results discussed herein deal with the removal of Rhodamine B (RhB) and Congo Red (CR) dye from wastewater by using multi-walled carbon nanotubes (MWCNTs) as an adsorbent. Different factors like solid dosage, initial pH and concentration, time, and temperature were studied to understand the behavior and mechanism of adsorption. The maximum adsorption capacity in case of a single component system was found to be 302 mg/g and 300 mg/g for Congo Red and Rhodamine B, respectively. Moreover, the mechanism of adsorption was best described by a pseudo-second-order kinetic model. Thermodynamic parameters showed that adsorption of CR and RhB was exothermic when these were removed from a single dye system. However, the overall process became endothermic for concurrent removal of both dyes from the solution. The research results showed that the MWCNTs could successfully be utilized to remove the dye from the industrial wastewater.

Morphological Spectrum and Survival Analysis of Diffuse Midline Glioma With H3K27M Mutation.

Background Diffuse midline gliomas with the H3K27M mutation are now recognized as separate entities due to their unique molecular signature, clinical features, and adverse outcome. Objective To determine the morphological spectrum and survival rate of diffuse midline gliomas with H3K27M mutation. Material and methods This retrospective study was conducted between January 2015 and January 2021 at Shaukat Khanum Memorial Cancer Hospital and Research Centre. Medical records of 28 cases of H3K27M-mutated midline gliomas were retrieved. Case slides were reviewed and the pertinent histological spectrum was evaluated. Results The mean age of patients was 24.36 ± 14.06 years. There were 21 (75%) males and 7 (25%) females. Biopsy was performed in 22 (78.6%), total resection in 1 (3.6%) while subtotal resection was done in 5 (17.9%) cases. Histologically, a spectrum of morphologies was noted with pilocytic astrocytoma (WHO grade 1) at one end and glioblastoma (WHO grade IV) at the other end. Immunohistochemically, all 28 cases were positive for Histone 3 immunohistochemistry. ATRX was performed in 7 (25.0%) cases with loss of ATRX expression in 3 (10.7%) and retained expression in 4 (14.3%) cases. Ki67 was <5% in 6 (21.4%), 5-10% in 1 (3.6%), 11-15% in 1 (3.6%), 16-20% in 3 (10.7%), 21-25% in 4 (14.3%), and 26-30% in 2 (7.1%) cases. The mean survival was 8.00 ± 9.39 months. Out of 28 patients, 15 (62.5%) patients died of disease. Conclusion Diffuse midline gliomas with H3K27M mutation is an aggressive entity with a broad morphological spectrum.

Dopamine Agonist-Induced Cerebrospinal Fluid Rhinorrhoea: A Case Report.

Introduction: Prolactinomas are the most common pituitary adenomas. Medical therapy with dopamine agonists (DAs) is the mainstay of treatment and rarely requires surgical manipulation. Patients may rarely present with cerebrospinal fluid (CSF) rhinorrhoea after starting therapy with DA in case of massive or invasive prolactinomas. Case Description: We present a case of a 29-year-old lady with invasive prolactinoma who presented with CSF rhinorrhoea after a month of starting bromocriptine therapy with the development of meningitis and warranting early surgical repair. Practical Implications: Patients with macroprolactinoma should be closely monitored initially after starting on DA to avoid life-threatening complications.

Toxicity Profile of Procarbazine Lomustine and Vincristine Chemotherapy in Low-Grade Glioma - Retrospective Review.

Background The role of Procarbazine Lomustine and Vincristine (PCV) chemotherapy is already established in terms of improving survival in low-grade glioma (LGG). This improved survival has led to the increasing administration of PCV to LGG patients over the past years. However, like other chemotherapies, serious hematological and non-hematological toxicities may occur. The purpose of this study was to evaluate the toxicity profile of PCV and its clinical relevance in our practice.  Materials and Methods We reviewed 63 patients of LGG retrospectively who received chemotherapy PCV between January 2015 and January 2018 at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore. Results Significant hematological toxicity as grade 3 anemia, thrombocytopenia, and neutropenia occurred in 19%, 27%, and 46% respectively with PCV. Other toxicities such as neurotoxicity, vomiting and derangement of liver enzymes occurred in 3.2%, 19%, and 19% respectively. Patients who were on concurrent anticonvulsants had no increase in PCV toxicity. Survival was not impacted by hematological toxicities up to grade 3. Conclusion PCV chemotherapy is associated with major hematological, hepatic, and clinical toxicities (vomiting, constipation, and neuropathy). Hematological toxicities influenced the course of treatment in terms of delays and interruptions.

A Prospective Analysis of Complications of Intracranial Tumor Surgery.

Aims There is a recent trend toward delivering neurosurgical care in large supraregional centers with intradepartmental subspecialization. We report a 14-year prospective audit of a single surgeon's experience of intracranial tumor surgery with an emphasis on complications. Methods A total of 616 procedures were performed on 596 patients of which 321 were male and 275 were female (age range: 1-84 years). Tumors were categorized as glioma, meningioma, metastasis, and other. Complications were recorded as infection, intracranial hematoma, neurologic deterioration, and death. Results Of the 305 patients who underwent glioma surgery, 4 (1.3%) developed a hematoma, 4 (1.3%) had neurologic deterioration, 5 (1.6%) died within 30 days of surgery, and 1 (0.33%) had an infection. Of the 120 patients who underwent surgery for meningioma, 8 (6.6%) developed an infection, 1 (0.83%) developed a hematoma, and 7 (5.8%) had neurologic deterioration. Of the 59 patients who underwent surgery for brain metastasis, 1 (1.7%) had neurologic deterioration. Of the remaining patients, 4 (3.0%) developed infection and 6 (4.5%) had neurologic deterioration. Conclusions The overall complication rate was infection, 2.1%; hematoma, 0.8%; neurologic deterioration, 2.9%; and death, 0.8%. These results compare favorably with published series.

Interdural Spinal Cyst: A Rare Clinical Entity.

BACKGROUND: For more than 2 decades, dural spinal cysts have been broadly classified as extradural and intradural. CASE DESCRIPTION: A 40-year-old woman presented with radicular thoracic pain. Intraoperative findings showed the cyst to be present within the dura itself. CONCLUSIONS: We suggest a revised classification of spinal dural cysts. This case highlights that, during surgery for spinal meningeal cysts, surgeons should bear in mind the possibility of an interdural cyst. This may help avoid inadvertent tears in the deep layers of such cysts, thus maintaining dural patency.

Intracranial dural arterio-venous fistula presenting with progressive myelopathy.

Spinal dural arterio-venous fistula (DAVF) is rare and usually involves the thoracic segments. The classical presentation is a slowly progressive ataxia. Clinical presentation of intracranial DAVF depends on the site of the DAVF, as well as the vessels involved. Patients may present with pulsatile tinnitus, occipital bruit, headache, dementia, visual impairment as well as neurological deterioration distant from the DAVF as a result of venous hypertension and cortical haemorrhage. The authors present a rare case of progressive myelopathy secondary to an intracranial DAVF.