Improvement in the quality of patient notes: A report of a closed loop audit quality improvement project at a neurosurgical department in Pakistan.

OBJECTIVE: To identify the deficiencies in patient note record-taking with the aim of improving the quality to meet international standards. METHODS: This prospective clinical quality improvement audit study was conducted at the department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore from January 2019 to February 2020. The first audit cycle was carried out in July 2019, after data anonymisation, the notes from 1st January to 31st June were analysed in the first audit cycle against a hybrid proforma containing entries deemed essential in operative notes according to the guidelines of the Royal College of Surgeons of England. The guidelines were subsequently disseminated among postgraduate trainees using various methods. Post-intervention, randomly selected patientnotes from 1st August to 31st December 2019 were analysed in the second audit which was done in February 2020. The result of the two audits were compared to assess significance of association between the cycles for each categorical variable. RESULTS: Of the 100 patient-notes audited, 50(50%) were part of each of the two cycles. Significant improvements (p<0.05) were seen between the two cycles in time of operation, pre-op status, post-op care, monitoring instruction, mobilisation, feeding instructions, wound care and position. There was 100% improvement in entries including name, age and sex, date of operation, elective/emergency, name of the procedure and name of operating surgeon and assistant, and the name of anaesthetist. Overall, marked improvement was observed in all parameters except in 'use of antibiotic prophylaxes'. CONCLUSIONS: Regular audits are needed to monitor and improve patient care.

Less disease severity of COVID-19 among smokers: An indication of investigating nicotine as preventive measure.

The study was aimed to mention the epidemiology of smoking in Pakistani COVID-19 infected patients along with the disease severity, oxygen dependency and fatality rate. A cross sectional epidemiological study was carried out on 555 confirmed cases of COVID-19 infection. The median age was 47±16 years. 59% were male and 41% were female. Most of the patients (97.5%) survived, while only 2.5% expired. 25.6% patients required the oxygen. Total 17 (3%) COVID-19 patients with age 20-75 years were identified as smokers. No mortality was observed in smokers. The 1.4% smokers presented with mild disease, 1.2% with moderate disease and 0.4% had severe disease. According to Chi-Square test, there existed an insignificant difference (p-value: 0.38649) between smokers and non-smokers in disease severity levels. Smoking is a precursor for countless diseases, but it behaved differently in COVID-19 infected patients, as its prevalence was significantly low. We found no significant variation of the disease severity among the smokers and non-smokers. Profound experiments should be conducted to recommend whether nicotine can be used as a protective agent to negate COVID-19 infection.

Correction to: Congenital pial AVF along the falx cerebri with complete agenesis of the corpus callosum and bilateral parasagittal pachygyria-polymicrogyria secondary to chronic ischemia.

The article which was recently published contained error. Fig. 1 was incorrectly processed as Fig. 2, resulting to identical figures during the publication the paper. Given in this article are the correct figures.

Congenital pial AVF along the falx cerebri with complete agenesis of the corpus callosum and bilateral parasagittal pachygyria-polymicrogyria secondary to chronic ischemia.

OBJECTIVE: Pial arteriovenous fistula (AVF) is an extremely rare entity due to direct arterial connection with the venous plexus without an intervening capillary network. The objective of this article is to describe a unique case of congenital pial AVF along the interhemispheric falx with complete callosal agenesis and malformation of cortical development within the bilateral anterior cerebral artery territories. We also demonstrated the distinctive feature of temporal stability of the extensive intracranial abnormalities without active intervention. Less than 100 cases have been reported thus far, most of which involve the adult rather than pediatric age group. A comprehensive literature review of congenital pial AVF will also be included. CASE DESCRIPTION: A 5-year-old child presented with headache and complex partial seizures. Imaging of the brain revealed the presence of polymicrogyria-pachygyria in the parasagittal frontoparietal lobes with associated underlying white matter hypodensities. Complete agenesis of the corpus callosum was also seen. In addition, enlarged and tortuous vessels were noted along the interhemispheric falx with no appreciable nidus. Bilateral dilated and tortuous ACAs were seen supplying the network of abnormal vessels along the falx. The radiological findings were stable on a follow-up MRI 12 years later. CONCLUSION: Our reported case adds to current limited knowledge of this rare entity in the pediatric age group, which is traditionally treated aggressively and urgently. Our case demonstrated temporal stability of this lesion with no detrimental complications observed. This suggests that the outcome of pial AVFs with conservative treatment may not be as grim as previously thought.

Impacts of intake of bakery food chemicals, degraded water and psychiatric drugs on liver & renal functions of brain tumor patients.

A chemically preserved food has raised mental health issues. Abnormalities in liver and kidney functions have been reported from mentally imbalanced individuals. This study was focused on finding anxiety issues and biochemistry alterations in brain tumor patients and in controls. The levels of liver & kidney enzymes were compared in both groups through Mann-Whitney U test. Kendall's tau-b correlation was conducted to determine that is there any relationship between anxiety levels and biochemistry parameters in both groups. There was more occurrence of severe anxiety levels (58%) in brain tumor patients. There were more mood swings in CG (64%) as compared to BP (48%). Less sleeping pattern was found in CG (42%) as compared to BP (37%). More patients (58%) were having severe anxiety levels as compared to CG (52%). 73% patients were having low levels of alkaline phosphatase (AP). 52% individuals in CG were having low levels of AP. AP was found significantly associated with anxiety levels in brain tumor patients only. A nutrient deprived food from preservation can reduce levels of alkaline phosphatase. This can impact metabolism of necessary minerals for proper brain function. This epidemiological study reports a significant association between anxiety and reduced AP levels.

Depression and dementia from hyponatremia in brain cancer patients exposed to frozen food chemicals.

Frozen food chemicals contain neurotoxins which disturb electrolyte levels. Altered electrolyte levels can induce mental illnesses. This study was focused on finding the prevalence of depression, dementia, intake of antidepressants and electrolytic alterations in brain cancer (BC) patients and in control group (CG) who were taking frozen and canned food. The levels of electrolytes were compared in both groups through Mann-Whitney U test. The Odds Ratio (OR) and Relative Risks (RR) were calculated of having a specific occurrence or condition of brain cancer patients vs. controls. Majority (41.42%) patients were from the age group 33-57 years. There were 52% male and 47% female patients. There was more occurrence of dementia (41%) and depression (6%) in patients as compared to CG. 94% patients were found with dementia. 32% patients were having low levels of sodium and 43% were having low levels of potassium. High levels of potassium (26%) were found in CG. 76% patients and 73% controls were taking canned food in moderation. 69% patients and 50% controls were taking frozen food in moderation. The potassium levels (p value: 0.00001) and sodium levels (p value: 0.01468) were found at significant difference in brain cancer patients and control group. Statistically significantly higher odds of outcome (OR>1) and increased relative risks (RR) were reported in dementia, depression and intake of anti-depressants for BC vs. CG. This epidemiological study reports hyponatremia as a significantly different parameter between brain cancer patients and controls. Food's chemicals induce hyponatremia, which can disturb mental states to develop different neurological conditions.

Long-term outcome of microvascular decompression for typical trigeminal neuralgia with autologous muscle: an analysis of 1025 patients from a developing country.

OBJECTIVE: The objective was to evaluate the long-term outcome of microvascular decompression (MVD) utilizing autologous muscle for trigeminal neuralgia (TGN). METHODS: A retrospective review was performed of all first-time MVD patients for typical classic TGN without prior surgical intervention who were treated between 2000 and 2019 at a tertiary supraregional neurosurgery practice. Demographic characteristics, surgical findings, operative results, complications, and recurrence rates at 1 year, 5 years, and last follow-up were collected. Pain outcome was assessed using the Barrow Neurological Institute (BNI) pain score. The chi-square test with continuity correction was used to compare categorical variables, and Kaplan-Meier curves and Cox regression were used to identify factors associated with recurrence. RESULTS: In total, 1025 patients were studied with a median (interquartile range [IQR]) (range) follow-up of 8 (5-13) (3-20) years. In the immediate postoperative period, 889 patients (86.7%) had complete pain relief and 106 (10.3%) had partial pain relief; neither group required medication, and 30 patients (2.9%) had no relief. One hundred forty-one recurrences (13.8%) occurred over a median (IQR) of 3 (2-6) years after surgery. The proportion of patients without recurrence was 97% at 1 year, 90% at 5 years, 85% at 10 years, 82% at 15 years, and 81% at 20 years. There was no significant difference in the probability of recurrence between patients with complete (114/907 [12.6%] recurrences) or partial (19/106 [17.9%] recurrences) postoperative pain relief (p = 0.124, log-rank test). Patients with venous compression (n = 322) had a significantly higher rate of MVD failure (n = 16 [5%]) compared to those with arterial compression (14/703 [2%]) (p = 0.015, chi-square test). In the Cox proportional hazards model, venous compression and lack of immediate postoperative pain relief had hazard ratios of 1.62 (95% CI 1.16-2.27) and 2.65 (95% CI 1.45-4.82) for recurrence, respectively. One hundred twenty-four (12.1%) complications were documented, including facial numbness (44 [4.3%]), facial nerve palsy (37 [3.6%]), CSF leak (13 [1.3%]), and diplopia (5 [0.5%]), which resolved in all patients. CONCLUSIONS: MVD with autologous muscle provides long-lasting pain relief in TGN patients with vascular compression with minimum morbidity and is a viable alternative to synthetic materials.

Rathke's cleft cyst abscess from Klebsiella.

Pituitary abscesses are uncommon lesions accounting for <1% of all pituitary diseases. We report a case of a female microbiology technician with a rare congenital heart disease who developed an Rathke's Cleft Cyst abscess from Klebsiella. A 26-year-old female biotechnician with a history of congenital heart disease and subclinical immunosuppression presented with a 10-month history of weight loss, amenorrhea, and visual deterioration. There was a history of previous unsuccessful transsphenoidal surgery. Radiology revealed a cystic lesion in the sellar region. The patient underwent an endoscopic endonasal intervention and the cystic cavity was washed with gentamicin, and the patient received meropenem postoperatively. The patient was followed up and had gradual improvement in her overall health, complete normality of her menstrual cycle, her visual field recovering to near normal and improving, no recurrence, and a stable cyst on magnetic resonance imaging.

Association of ABO Blood Group with Delayed Cerebral Ischemia and Clinical Outcomes Following Aneurysmal Subarachnoid Hemorrhage in Pakistan.

Background The ABO blood type, due to its various hemostaseologic properties, has been associated with several vascular diseases, including aneurysmal subarachnoid hemorrhage (aSAH). However, the role of ABO blood type in delayed cerebral ischemia (DCI) onset and other clinical outcomes after aSAH is largely unexplored. This study aimed to investigate the association between ABO blood type and outcomes after aSAH, primarily DCI. Methods A retrospective analysis was made on the data collected from 175 aSAH patients at a tertiary supraregional neurosurgery department over 5 years. Socio-demographic factors, clinical variables (DCI, mFG, WFNS grade, and Glasgow Outcome Scale at discharge), EVD placement, and aneurysm size were analyzed for their association with ABO blood type. Results DCI was reported in 25% of patients with 'O' blood type and 9.6% with 'non-O' blood type. A stepwise logistic regression model showed that after adjusting for BMI, mFG, WFNS grade, and EVD placement, 'O' type blood group was an independent risk factor for DCI, greatly increasing the risk of DCI as compared to 'non-O' type groups (OR = 3.27, 95% CI: 1.21-8.82). Conclusion This study provides evidence that individuals with 'O' blood type may have a higher risk of DCI onset after aSAH. However, further studies are essential to address the limitations of our work and confirm our findings.

Isolated subdural hematoma due to dengue hemorrhagic fever: Surgical intervention and review of the literature.

Background: Central nervous system (CNS) complications of dengue fever, a mosquito-borne single standard RNA virus illness, are reported in <1% of all cases. Hemorrhagic complications in severe forms of the disease can be life-threatening. The literature on cases, where hemorrhagic CNS complications necessitated neurosurgical intervention, is exceedingly sparse. The authors report their experience of a patient who developed an isolated acute subdural hematoma (SDH) due to dengue hemorrhagic fever (DHF) in the critical period of the illness with a poor prognosis. Despite a moribund patient, the SDH was immediately evacuated, achieving a good outcome. Case Description: A 65-year-old male patient was admitted with high-grade febrile illness and diagnosed with dengue. The patient had no focal neurology and was managed adequately following the primary survey on admission but, then, developed severe thrombocytopenia and eventually the critical phase of dengue illness. On the 5th admission day, the patient collapsed. Glasgow Coma Score was 3/15 with bilaterally dilated, fixed pupils. Immediate computed tomography head revealed a large left SDH with a significant midline shift. SDH was emergently evacuated with two units of platelets transfused peroperatively and two additional units postoperatively. Thrombocytopenia resolved within 48 h, and interval scanning showed gradual resolution of SDH. The patient was discharged 18 days later. Five months later, on follow-up, the patient is well with mild left-sided weakness and an Extended Glasgow Outcome Score of 7. Conclusion: Isolated SDH is a rare but life-threatening hemorrhagic complication of DHF. Even in the critical phase of illness, with severe thrombocytopenia, surgical evacuation should be considered if the SDH is present in isolation, within an accessible area, and can be operated on immediately.

Prospective Elective Neurosurgical Theater Utilization Audit in Pakistan: Problems in a Public Tertiary Care Hospital and Proposed Solutions from Lower-Middle-Income Country.

Background In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature. Materials and Methods We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time. Results Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff. Conclusion Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization.

Early experience with patient-specific low-cost 3D-printed polymethylmethacrylate cranioplasty implants in a lower-middle-income-country: Technical note and economic analysis.

Background: Polymethyl methacrylate (PMMA) cranioplasty, while widely prevalent, has limitations associated with freehand manual intraoperative molding. PMMA has been superseded by titanium or Polyetheretherketone implants, prefabricated commercially from preoperative CT scans, and boasting superior clinical and cosmetic outcomes. However, such services are extremely inaccessible and unaffordable in the lower-middle-income country (LMIC) settings. The study aims to describe, in detail, the process of making ultra-low-cost patient-specific PMMA cranioplasty implants with minimum resources using open-access software. We report the first such service from the public health-care system within Pakistan, a LMIC. Methods: Using open-source software, preoperative CT heads were used to prefabricate three-dimensional implants. Both implant and cranial defects were printed using polylactic acid (PLA) to assess the implant's size and fit preoperatively. From the PLA implant, we fashioned a silicon mold that shapes the PMMA implant. Ten patients who underwent cranioplasty using our technique for various cranial defects with at least a 12-month follow-up were retrospectively reviewed. Clinical, cosmetic, and radiological outcomes were objectively assessed. Results: Etiology of injury was trauma (8), malignant MCA infarct (1), and arteriovenous fistula (1). We produced seven frontotemporal-parietal implants, one bifrontal, one frontal, and one frontoparietal. At 1 year, eight patients reported their cosmetic appearance comparable to before the defect. Radiological outcome was classified as "excellent" for eight patients. No postoperative complications were encountered, nor did any implant have to be removed. One patient's implant involving the orbital ridge had an unsatisfactory cosmetic outcome and required revision surgery. The average cost per implant to the National Health Service was US$40. Conclusion: Prefabricated patient-specific PMMA cranioplasty implants are cost-effective. A single surgeon can fashion them in a limited resource setting and provide personalized medicine with excellent clinical/cosmetic-radiological results. Our method produces patient-specific cranioplasty implants in an otherwise unaffordable LMIC setting.

Lhermitte-Duclos Disease: A Rare Cerebellar Hamartoma Presenting Following Traumatic Brain Injury And A Review Of The Literature.

Lhermitte-Duclos Disease (LDD) is an extremely rare hamartoma of the cerebellum and is associated with the cancer syndrome Cowden's disease. We report such a patient whose disease was diagnosed incidental to traumatic brain injury. A 40-year-old male presented after fall from stairs. CT scan revealed a large lesion in the right cerebellar hemisphere. Clinical history recounted multiple short episodes of vomiting (>10 a week) for the past 30 years and development of posterior fossa symptoms over the recent months. Neither of these had him referred due to lack of access to primary healthcare. T1 MRI with contrast showed an isointense focal mass, enhancement along the folia, and distortion of the 4th ventricle. On T2 MRI, tiger striped appearance was noted. Endoscopic third ventriculostomy was performed followed by gross total resection of the hamartoma. Histology confirmed LDD. All reported symptoms resolved following surgery. Due to lack of access to the expensive genetic testing for Cowden's he is in regular biannual follow up to be evaluated clinically for associated malignancies. We present this case to highlight the clinical-pathological characteristics of LDD, its treatment, and discuss management in the absence of genetic testing in our socio-economic demographic.

Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country.

BACKGROUND AND OBJECTIVE: The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas. METHODS: A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded. RESULTS: All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone-secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed. CONCLUSIONS: iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.

Traumatic Brain Injury in Underage Motorcycle Drivers: Clinical Outcomes and Sociocultural Attitudes from a Lower-Middle-Income Country.

BACKGROUND AND OBJECTIVE: Poor societal attitudes and inadequate law enforcement have greatly contributed to the increase in underage motorcycle driving in Pakistan. This study reports the burden of traumatic brain injury (TBI), clinical characteristics/outcomes, and reason for driving in underage motorcyclists. MATERIALS AND METHODS: A prospective study was conducted throughout 2021. Demographics, mechanism of injury, helmet use, number of passengers, clinical outcomes, reason for driving and parental awareness/consent status, referral pathway, and transport duration were documented. RESULTS: Of a total of 1052 motorcyclists with TBI, 112 were underage drivers. The mean age was 14.7 years (range, 10-17 years); 98.2% were male and 17% wore protective helmets. The most common reason for driving was recreational, followed by for domestic chores. In 66 patients, there was parental awareness and 30 of these patients had active parental consent. These patients reported domestic chores as the reason for their journey, whereas recreational purposes were a more prevalent reason in patients without parental awareness/consent (P < 0.001). Most patients were brought by provincial ambulance service (response time 12.8 minutes). Some patients came from peripheral hospitals (26.8%) and private hospitals (14.3%) that lacked neurosurgical cover, and these were associated with severer baseline injuries (P < 0.001). The average stay was 6.5 days, and 75.9% of patients were discharged with a good Glasgow Outcome Scale score. CONCLUSIONS: Most underage patients with TBI resulting from motorcycle driving are adolescent boys who do not use helmets. Trauma prevention systems and involvement of multiple stakeholders are needed to reduce underage driving. Efficient referral systems must transport patients to appropriate neurosurgical cover, which is lacking outside major cities.

Outcome of surgical treatment for neglected congenital muscular torticollis: A series of 28 adolescent patients.

Background: Congenital muscular torticollis (CMT) is a common musculoskeletal anomaly that can be excellently managed at birth with conservative physiotherapy; as a result, literature on neglected cases of CMT in older patients is sparse, and there is controversy regarding the ideal surgical approach. This report aims to provide the outcome of 28 adolescent patients with neglected CMT who underwent unipolar release at the distal sternocleidomastoid muscle (SCM). Methods: Twenty-eight adolescent patients with untreated CMT presented to our department between 2016 and 2019 and underwent unipolar release at the distal end of their SCM. All patients had no other anomaly based on clinical examination and radiological investigations. At the time of surgery, the mean age of patients was 15.8 years (range 13-18 years). There were 10 male and 18 female patients with the right side affected in 20 cases. All patients were followed up for 2 years. Patients were evaluated using an adapted version of the modified Lee's scoring system to assess cosmesis and the cervical-mandibular angle (CMA) to assess radiological change. Results: The adapted modified Lee's scoring system indicated 17 patients (60.7%) had an excellent outcome, 6 patients (21.4%) had a good outcome, and 5 patients (17.9%) had a fair outcome. In particular, scarring was fine in 23 patients (82.1%) and only slight in the remaining. Independent to the categorical outcome, all patients subjectively reported high satisfaction with their cosmesis. The preoperative mean CMA was 19.6° (range, 8.5-31.5°), which was reduced to a mean of CMA of 14.0° (range, 3-28°) after surgery (P < 0.05). No patient developed any permanent complication or required surgery for recurrence. No serious postoperative complications such as infection or hematoma were observed. Conclusion: In uncomplicated cases of neglected CMT in adolescent patients, unipolar tenotomy of the distal SCM is a safe and reliable technique with good clinical outcomes.

Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: Unfolding of an underrated comorbidity.

BACKGROUND: Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view. METHODS: A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital's pediatrics' anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented. RESULTS: The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic. CONCLUSION: Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.

Role of intraoperative computed tomography scanner in modern neurosurgery - An early experience.

BACKGROUND: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner's use in a wide range of technically challenging neurosurgical cases. METHODS: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. RESULTS: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. CONCLUSION: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow.

Applying a governance barometer to vaccine delivery systems: Lessons from a rural district of Pakistan.

INTRODUCTION: Weak vaccine delivery systems in countries off-track for routine immunization targets, need in-depth evidence on system level barriers to be critically resourced and monitored. We applied a Balanced Score Card (BSC) approach in a rural underserved district of Pakistan to (i) identify critical areas needing support in the government vaccine delivery system; and (ii) for benchmarking improvements in the vaccine delivery system. METHODOLOGY: BSC was developed drawing on desk review, government consultations and field testing. 45 immunization indicators were finalized across 8 domains: human resource; vaccine supply; safe vaccination practice; cold chain maintenance; outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Data were collected through health facility assessments, client exit interviews and household vaccination assessment. A composite score was calculated for each domain and banded into unsatisfactory, borderline and satisfactory categories. 5 lowest ranking domains were targeted for 2 years of health systems strengthening (HSS) interventions. Post-intervention assessment tracked progress. RESULTS: The district obtained a cumulative score of 51% (unsatisfactory) at pre-intervention and improved to 82% (satisfactory) at post-intervention. At pre-intervention, 4 domains scored satisfactory and 4 scored unsatisfactory. Unsatisfactory scores were received for: outreach preparedness; records & supervision; verifiable vaccination volume; and client communication. Post intervention 6 of 8 domains scored satisfactory and 2 moved from unsatisfactory to borderline. Highest percentage point (pp) improvements were seen in outreach preparedness (53 pp, p = 0.01), EPI supervision (52 pp, p = 0.01) and verified vaccination volume (46 pp, p = 0.02). 3 domains that were not intervened through HSS interventions had minimal change in scoring - cold chain maintenance (6 pp), safe vaccination practice (12 pp) and vaccine supply (11 pp). CONCLUSION: BSC served to prioritize interventions towards critical unmet needs for vaccine delivery in the district health system and particularly helped to improve outreach preparedness, EPI supervision and verified vaccination volume.

Operability, Acceptability, and Usefulness of a Mobile App to Track Routine Immunization Performance in Rural Pakistan: Interview Study Among Vaccinators and Key Informants.

BACKGROUND: There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems. OBJECTIVE: This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan. METHODS: An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas. RESULTS: Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data. CONCLUSIONS: Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.