Non-granulomatous meningoencephalitis with Balamuthia mandrillaris mimicking a tumor: First confirmed case from Pakistan.

Background: Free-living amoebae rarely instigate intracranial infections that may resemble neoplastic conditions on imaging. Naegleria fowleri precipitates an acute, swiftly fatal meningoencephalitis, whereas Acanthamoeba and Balamuthia species typically manifest with a less aggressive onset but carry equally dire consequences. Case Description: The case describes a 33-year-old woman with subacute encephalitis caused by Balamuthia mandrillaris. She experienced 2 months of back pain, 1 month of headaches, and 2 weeks of vomiting without fever, recent travel, aquatic activities, or animal exposure. Brain magnetic resonance imaging revealed a sizable, heterogeneous enhancing mass in the right temporal and frontal lobes, accompanied by vasogenic edema and midline shift. Histopathology showed marked inflammation and damage to blood vessels with amoebic trophozoites present. The trophozoites displayed specific characteristics, leading to the diagnosis of amoebic meningoencephalitis. Polymerase chain reaction and Sanger sequencing confirmed B. mandrillaris infection while testing for N. fowleri and Acanthamoeba was negative. Despite antibiotic treatment, the patient's condition deteriorated rapidly, resulting in death within 2 weeks of presentation. Conclusion: This is the first confirmed case of B. mandrillaris central nervous system (CNS) infection from Pakistan. The incidence of this disease is expected to rise due to increasing temperatures due to climate change and the deteriorating quality of the water supply. Balamuthia meningoencephalitis should, therefore be on the differential for non-neoplastic CNS lesions. Furthermore, an atypical histopathologic picture, including the absence of granulomatous inflammation, needs to be recognized.

Patient-Reported Outcomes and Complications of Simultaneous versus Staged Surgical Decompression for Tandem Spinal Stenosis.

Introduction Tandem spinal stenosis (TSS) refers to the narrowing of the spinal canal at two distinct anatomic areas. Symptoms can present due to either cervical myelopathy or lumbar stenosis. Consequently, determining the symptomatic anatomical levels requiring surgery can pose a challenge. We sought to identify the surgical approach associated with better patient-reported outcomes. Materials and Methods The Information Management System was queried using the International Classification of Diseases Ninth and Tenth Edition codes to identify patients who underwent simultaneous or staged decompression surgery for TSS between 2011 and 2020. Patient records were reviewed to collect data on age, sex, comorbidities, surgical approach, modified Japanese Orthopedic Association (mJOA) score, and complications. The mJOA is a validated composite assessment used to quantify postoperative neurological status. Multivariable regression models were utilized to identify factors associated with better postoperative neurological recovery. Results Among 42 patients included in the analytical cohort, 33 (78.6%) underwent simultaneous cervical and lumbar decompression, while 9 (21.4%) underwent staged decompression (cervical followed by lumbar). The patient's age, sex, comorbid conditions, and American Society of Anesthesiologists level were similar between the two groups. Furthermore, simultaneous decompression was associated with higher blood loss (676.97 vs. 584.44 mL) and an increased need for transfusion (259.09 vs. 111.11 mL) compared with staged decompression. Moreover, patients who underwent simultaneous decompression experienced a higher number of postoperative complications (10 vs. 1; p = 0.024). Notably, postoperative mJOA scores improved in both groups; however, the improvement was more pronounced in the staged group (mJOA score: 15.16% [ ± 2.18] vs. 16.56% [ ± 1.59]). On follow-up visits, patients who underwent staged decompression showed better recovery rates (mJOA score: 78.20% [ ± 24.45] vs. 59.75% [ ± 25.05]). Conclusion The patient's clinical history and examination findings should be the main determinants of surgical decision-making. Our study showed a slightly higher postoperative mJOA score and a recovery rate with fewer complications in staged decompression of TSS.

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.

First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases.

BACKGROUND: Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks. METHODS: Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs. RESULTS: Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP. CONCLUSIONS: Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Are Thinking Machines Breaking New Frontiers in Neuro-Oncology? A Narrative Review on the Emerging Role of Machine Learning in Neuro-Oncological Practice.

Medical science in general and oncology in particular are dynamic, rapidly evolving subjects. Brain and spine tumors, whether primary or secondary, constitute a significant number of cases in any oncological practice. With the rapid influx of data in all aspects of neuro-oncological care, it is almost impossible for practicing clinicians to remain abreast with the current trends, or to synthesize the available data for it to be maximally beneficial for their patients. Machine-learning (ML) tools are fast gaining acceptance as an alternative to conventional reliance on online data. ML uses artificial intelligence to provide a computer algorithm-based information to clinicians. Different ML models have been proposed in the literature with a variable degree of precision and database requirements. ML can potentially solve the aforementioned problems for practicing clinicians by not just extracting and analyzing useful data, by minimizing or eliminating certain potential areas of human error, by creating patient-specific treatment plans, and also by predicting outcomes with reasonable accuracy. Current information on ML in neuro-oncology is scattered, and this literature review is an attempt to consolidate it and provide recent updates.

Frequent inappropriate use of unweighted summary statistics in systematic reviews of pathogen genotypes or genogroups.

OBJECTIVES: Our study aimed to systematically assess and report the methodological quality used in epidemiological systematic reviews (SRs) and meta-analysis (MA) of pathogen genotypes/genogroups. STUDY DESIGN AND SETTING: Nine electronic databases and manual search of reference lists were used to identify relevant studies. The method types were divided into three groups: 1) with weighted pooling analysis (which we call MA), (2) unweighted analysis of the study-level measures (which we call summary statistics), and (3) without any data pooling (which we call SR only). Characteristics were evaluated using Assessment of Multiple Systematic Reviews (AMSTAR), Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Risk Of Bias In Systematic reviews (ROBIS) tools. The protocol was registered in PROSPERO with CRD42017078146. RESULTS: Among 36 included articles, 5 (14%) studies conducted SR only, 16 (44%) performed MA, and 15 (42%) used summary statistics. The univariable and multivariable linear regression of AMSTAR and PRISMA scores showed that MA had higher quality compared with those with summary statistics. The SR only and summary statistics groups had approximately equal scores among three scales of AMSTAR, PRISMA, and ROBIS. The methodological quality of epidemiological studies has improved from 1999 to 2017. CONCLUSION: Despite the frequent use of unweighted summary statistics, MA remains the most suitable method for reaching rational conclusions in epidemiological studies of pathogen genotypes/genogroups.

Exposure to violence and its association with symptoms of aggression: A cross sectional study among medical students of Karachi, Pakistan.

OBJECTIVE: To explore the experience of violence and its association with symptoms of aggression among medical students. METHODS: The cross-sectional study was conducted from January 5 to 14, 2018, at Dow University of Health Sciences, Karachi, and comprised medical students who were interviewed using a self-reporting questionnaire that had three sections: demographics, the Aggression Questionnaire, and the Exposure to Violence Scale. Data were analysed using SPSS 20.. RESULTS: Of the 192 subjects, 144(75%) were females and 48(25%) were males, with an overall mean age of 21.39+/- 2 years. Total exposure to violence was significantly higher among older male respondents (p<0.05). It was significantly associated with higher severity of physical aggression and hostility (p<0.05). However, it had no significant relationship with verbal aggression and anger (p>0.05).. CONCLUSIONS: A large proportion of medical students reported exposure to violent events, which was also associated with increased aggression among them.