Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country.

BACKGROUND: Esophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. METHODOLOGY: A prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. RESULTS: A total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30-38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. CONCLUSION: Minimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.

Role Of Shear Wave Elastography In Assessment Of Placental Elasticity In Normal And High-Risk Pregnancies In Third Trimester.

Objective: To assess the elasticity of placenta using shear wave elastography in normal and high-risk pregnancies in the third trimester. METHODS: The prospective, observational study was conducted at the Dow Institute of Radiology, Dow University of Health Sciences, Karachi, from September 15, 2022, to January 15, 2023, and comprised singleton pregnant women during 28-40 weeks of gestation who were referred from the obstetric department. The subjects were divided into normal pregnancy group A and high-risk pregnancy group B. Risk factors include gestational hypertension, gestational diabetes, intrauterine growth restriction, placenta previa, morbidly adherent placenta, old primigravida, teen age and morbid obesity were noted. All the patients underwent grey scale, Doppler ultrasonography and shear wave elastography. Data was analysed using SPSS 26. RESULTS: Of the 104 subjects, 78(75%) were in group A and 26(25%) were in group B. The overall mean age was 34.2±3.59 years. In group B, mean placental shear wave velocity was 2.34±1.17m/sec and elasticity was 24.41±25.51kPa compared to 1.42±0.55 m/sec and 13.6±10.23kPa in group A (p<0.05). Significant positive correlation was found between shear wave velocity and elasticity values in both groups (p<0.001). Conclusion: Shear wave elastography was found to be a useful technique in detecting placental stiffness, and can be used as an adjunct to the currently available ultrasonographic methods in high-risk pregnancies.

Association of plasma folic acid, vitamin-B12 and homocysteine with recurrent pregnancy loss. "A case control study".

Objective: To investigate the relationship of serum homocysteine, folic acid, and vitamin-B12 levels with recurrent pregnancy loss (RPL). Methods: A case-control study was conducted in the Department of Gynecology and Obstetrics, Dr. Ruth Pfau Civil Hospital, Karachi from July 2021 to June 2022. Total 124 participants were recruited from gynecology outpatient department after taking informed consent. The participants included 62 non-pregnant females with two or more consecutive unexplained RPLs and 62 healthy women having at least two successful deliveries without any pregnancy loss. Serum folic acid and vitamin-B12 levels were measured by chemiluminescent method and serum homocysteine was measured by enzyme-linked immunosorbent assay (ELISA). Comparison of quantitative variables with RPL cases and control was done by Mann-Whitney U-test (for non-normally distributed data) and independent sample t-test (for normally distributed data), while Pearson's chi-square test was used for the association of qualitative variables with RPL cases and control. Correlation of homocysteine with vitamin-B12 and folic acid was assessed in RPL cases. Results: The median age of the study population was 27 (IQR 25-32) years. The median body mass index (BMI) was 26.25 (IQR 22-29) kg/m2. Cases had significantly lower serum folic acid (p-value=0.022), while vitamin-B12 was decreased in cases as compared to controls (p-value=0.295). Mean concentration of serum homocysteine was higher in RPL cases as compared to controls (p-value=0.094). There was significant association of serum vitamin B12 (p-value=0.001) and folic acid levels (p-value=0.004) with RPL. The homocysteine was not significantly correlated with vitamin-B12 (r=0.124, p=0.338) and folic acid (r=0.067, p=0.606) in the RPL group. Conclusion: Reduced level of serum folic acid and vitamin B12 was significantly associated with RPL cases, while homocysteine was marginally raised however the difference was not significant. Folic acid and vitamin B12 supplementation before next pregnancy in RPL patients is likely to be beneficial in improving pregnancy outcomes.

Forecasting Total Fertility Rates For Urban And Rural Areas In Pakistan With A Coherent Functional Model.

OBJECTIVE: To project total fertility rates for urban and rural areas in Pakistan up to 2027 with 80% prediction intervals. METHODS: The secondary-data study was conducted from March 2020 to August 2020 at Data Bank in the Department of Statistics, University of Karachi, Pakistan, and comprised publicly available data of the Pakistan Demographic Survey from 1984 to 2007. Two statistical models, the functional time series model and the coherent functional model, were used to make the predictions about age-specific fertility rates. The forecasting performance of the models was compared through error measures. Data was analysed using R version 3.6.3. RESULTS: The predicted total fertility rate was 1.7 (80% prediction interval: 0.4-4.4) births per woman for urban areas and 2.2 (80% prediction interval: 0.6-5.3) births per woman for rural areas in 2027 using coherent functional model. The total fertility rate predicted by the functional time series model was 2.1 (80% prediction interval: 1.6- 2.6) births in urban areas and 2.7 (80% prediction interval: 1.7-4.1) births per woman in rural areas. The empirical comparison of forecast error measures obtained from the two models indicated that the coherent functional model performed better for forecasting total fertility rates for urban and rural areas in Pakistan. CONCLUSIONS: The projection of fertility rate obtained by the functional time series model and the coherent functional model described the future fertility behaviour of urban and rural populations.

Patterns of musculoskeletal disorders in health care providers and their association with ergonomic risks.

Objectives. Musculoskeletal disorders (MSDs) have a high prevalence among allied health care providers because of the demanding nature of their work and lack of practicing proper ergonomics. The aim of this study focused on patterns of work-related musculoskeletal disorders (WMSDs) affecting different health care providers working in a different unit of a tertiary care hospital. Methods. This cross-sectional study collected data from 2000 allied health care providers working at various departments of Civil Hospital and Dow University Hospital of Karachi (DUHS), via self-administered questionnaire, based on Occupational Safety and Health Administration (OSHA) guidelines. Results. Our findings revealed that 92.9% of individuals had MSDs as a result of poor ergonomics, with 93% reporting that the disease interferes with their normal job routine. Conclusions. Medical technologists are the most affected group among allied health care workers. Lack of knowledge and improper ergonomic culture results in such a high prevalence rate in allied health care workers in Pakistan.

Fludarabine/Cyclophosphamide Conditioning Regimen in Aplastic Anemia Patients Receiving Matched-Sibling Donor Transplant Is Non-inferior to ATG/Cyclophosphamide: A Single-Center Experience from Pakistan.

The successful outcome of allogeneic hematopoietic stem cell transplant (HSCT) in aplastic anemia patients is driven by suitable donor selection, appropriate conditioning regimen, early intervention, and optimal supportive care after transplant. Pakistan, being a developing country, faces grave economic challenges due to meager health care budget; therefore, cost constraints remain the foremost impediment in optimizing transplant facilities for socioeconomically deprived patients. We conducted a single-center retrospective analysis of aplastic anemia patients (N = 130), who received matched sibling donor transplants from 2011 to 2019, treated with either fludarabine/cyclophosphamide (Flu/Cy) or antithymocyte globulin/cyclophosphamide (ATG/CY) conditioning regimen. Median age was 16 years (IQR, 11-20), and it ranged from 3 to 48 years. The median time from diagnosis to transplant was 3 months (IQR, 2 to 4), and it ranged from 1 to 8 months. The estimated overall survival (OS), relapse-free survival (RFS), and GvHD-free survival (GFS) were found to be 69.0%, 66.7%, and 64.3% in the ATG/Cy group while 76.1%, 72.7%, and 62.5% in the Flu/Cy group, respectively, after a median follow-up of 30 months (IQR, 8 to 55), and it ranged from 0 to 98 months for the study groups. The Flu/Cy regimen was well tolerated and was not associated with increased risk of GvHD. Hence, it may be an appropriate alternative conditioning regimen for developing countries with limited health care resources.

Clinicopathologic features and prognostic grouping of gastrointestinal stromal tumors (GISTs) in Pakistani patients: an institutional perspective.

OBJECTIVES: Gastrointestinal stromal tumors (GISTs) are rare tumors of gastrointestinal tract, prognosis of which largely depends upon histopathologic characteristics of resection specimens, which were not widely studied in our population. Therefore we aimed to evaluate the histopathologic characteristics of GISTs in our population and their prognostic grouping according to college of American pathologist's guidelines. RESULTS: Mean age of patients was 53.4 years (18-71 years). 92% of cases were of primary GISTs and stomach was the most common site (57.7%). 75% of cases were of spindle cell morphology and 53.8% belonged to high risk prognostic group. Comparison of stomach and intestinal GISTs showed that intestinal GISTs were found to be of high grade (70%) and of high risk prognostic group (75 and 80%) compared to stomach GISTs (43% were of high risk prognostic group), however this finding was not statistically significant. GISTs are infrequent gastrointestinal tumors but early diagnosis and identification of adverse histological features are key to successful treatment. We found a large majority of GISTs to be located in stomach, however intestinal GISTs were found more likely to be associated with adverse prognostic parameters. However more large scale studies are warranted to establish this finding.