Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan.

BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of the Service Delivery Challenges.

INTRODUCTION: Brain tumors pose a major challenge in low- and middle-income countries (LMICs) due to limited resources and high costs, resulting in hampered service delivery of neurosurgical care and significant disparities in patient outcomes compared to high-income nations. Therefore, our systematic review aims to identify barriers to service delivery in providing adequate surgical care for the management of brain tumors in LMICs. METHODS: We searched Scopus, PubMed, Google Scholar, and CINAHL, from inception to October 20, 2022. The data from the eligible studies were extracted and analyzed qualitatively. RESULTS: The final analysis included 35 articles, which highlighted significant challenges in providing adequate surgical care for brain tumors in LMICs. Among the cited studies, 10% reported lack of multidisciplinary team structures, 61% noted delayed patient presentation, 16% highlighted delays in neuroimaging, 10% reported delays in scheduling surgery, lack of training for specialized surgery (3%), lack of intra-operative facilities (19%), power supply interruption (6%), and lack of advanced diagnostic and specialized surgery facilities (19%). Strategies for addressing these challenges include cross-border collaboration (7%), public education, and awareness (13%), establishing multidisciplinary teams (20%), utilizing alternative surgical techniques (13%), 7% intraoperative ultrasound, 13% intraoperative cytology smear), and establishing satellite hospitals for low-risk care (7%), standard operating procedure and infection control (13%). CONCLUSION: Targeted interventions considering economic constraints are essential to improve the availability, affordability, and quality of neuro-oncologic services in developing countries. International collaborations and building capacity are vital for improving patient outcomes and service delivery, as well as forming multidisciplinary teams and utilizing resource-saving, innovative methods.