Search

Background: Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Current treatment protocols include stereotactic radiosurgery, transarterial embolization, and surgical resection under general anesthesia. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes. Objectives: We reviewed the current literature reporting surgical outcomes and assessed the feasibility of AC for AVM resection. Methods: The PRISMA guidelines were utilized as a template for the review. Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed. Results: 12 studies were included with a total of 122 AVM cases. Spetzler–Martin grading was used for the classification of the AVMs. The asleep–awake–asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n = 2) and bleeding (n = 4). Short-term post-operative complications included hemorrhage (n = 3), neurologic dysfunctions including paresis (n = 3), hemiplegia (n = 10), dysphasia/aphasia (n = 6), cranial nerve dysfunction (n = 3), and pulmonary embolism (n = 1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups. Conclusion: AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas as mapping during AC identifies the eloquent cortex thus promoting careful tissue handling which may preserve neurologic function and/or predict the postoperative functional status of the patients We, therefore, conclude that AC is a viable modality for AVMs resection near eloquent language and motor areas.

Objective: To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source. Methods: A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of. Conclusion: The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally. Keywords: brain neoplasms, retrospective study, epidemiology, noncommunicable diseases. Continue...

Abstract Background Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is an uncommon variant of Hodgkin lymphoma. There is limited data on treatment, management of refractory and relapsed disease, and long-term outcome. Many registries or country-wide data reports are unable to provide detailed primary and subsequent management. We are reporting our observation on patient’s characteristics, management, and outcome. Methods This single-institution retrospective cohort analysis includes NLPHL patients seen from 1998 to July 2019. We used Fisher’s exact test, chi-square, and Kaplan-Meier (KM) method for various analyses. Results Two hundred patients were identified, (6.34% of all the HL). Male:female was 3:1. The median age at diagnosis was 22 years (4–79 years). Stage I-II in 145 (72.5%) cases. One hundred patients (50%) received chemotherapy, 68 (34%) chemotherapy + radiation therapy (RT); 87% of all chemotherapy was ABVD (adriamycin, bleomycin, vinblastine, dacarbazine). Thirteen patients (6.5%) received RT alone and 16 (8%) had surgery alone. Complete response in 82%, partial response in 5.5% and progressive disease in 10.5%. The median follow is 60 months (5–246). Median 5 and 10 years overall survival (OS) is 94.8 and 92.4% (stages I-II, 97.7 and 97.7%, stage III-IV, 94.8 and 92.4%). Median event-free survival (EFS) is 62.3 and 54% respectively (stage I-II, 72 and 64%, stage III-IV, 36.4 and 18.2%). Stage I-II vs III-IV OS (p =

Abstract Background Familial clustering of lymphoid and/or hematological malignancies (FHM) provides an opportunity to study the responsible genes. The data is limited in patients with lymphoid and hematological malignancies. Methods The lymphoma database was used to identify patients seen in our institution from 1998 to 2019 with nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL). We studied FHM by collecting detailed history of any malignancy in the family (FM). Results Two hundred NLPHL patients were identified. Contacting was not possible in 30 patients due to no response to the phone calls (22) and death [1]. 170/200 patients were interviewed; represented 167 families (3 patients with a family member with NLPHL). These 170 patients provided information about 8225 family members. These 167 families had a total of 329 family members with 334 malignancies (including 167 NLPHL patients and 5 members with 2 malignancies each). Of these 167 patients, 77 (46.1%) had no FM while 90 (53.9%) patients had a positive FM; 162 family members with 167 malignancies. Among these 167 families, 31 families (18.6%) had members with FHM +/− solid cancers. These 31 families had 35 family members (25 males:10 females) with 16 lymphomas: diffuse large B cell lymphoma [2], follicular center cell lymphoma [3], chronic lymphocytic leukemia/small lymphocytic lymphoma [3], non-Hodgkin lymphoma [2], classical HL [2], and NLPHL [4]. Total of 8 leukemia: acute lymphoblastic leukemia [4], acute myeloid leukemia [3], and leukemia - no subtyping [5]. These 35 FHM members are 1st [6], 2nd (16), and 3rd [7] degree relatives of 31 NLPHL patients. There are 4 families with NLPHL in family members; all these 8 NLPHL patients are male and are alive. The median total number of 1st + 2nd +3rd degree members are 81. The decrease in the age of diagnosis from 1st generation to the 2nd generation (anticipation) was noted in 13/17 patients; 2nd generation median age at diagnosis was 29.7 years vs 1st generation age 53 years (developed malignancy 23.3 years earlier). Conclusion FHM is frequent in NLPHL. This study provided us many important insights for planning future studies in terms of interviewing technique, time, and resource allocation and genetic testing.

Objective: The objective of this study is to determine the role of preoperative coagulation studies in predicting intraoperative blood loss, in patients undergoing elective craniotomy in our tertiary hospital setting. Materials and Methods: This was a Quasi-experimental study conducted at Department of Neurosurgery, Aga Khan University Hospital Karachi for a duration of 6 months. A non-probability consecutive sampling technique was employed. All admitted neurosurgery patients for elective craniotomy were enrolled and followed as part of the study. Laboratory values including baseline workup e.g. Complete Blood count, PT, activated Partial Thromboplastin Time (aPTT), Internationalized Ratio (INR) were taken preoperatively and postoperatively. A predesigned questionnaire for the collection of data was used, which included demographics and clinical information. Approval from the university ethical committee was obtained before starting the study. Data was entered and analysed into SPSS version 21. Effect modifier age, gender, co-morbids, type, and duration of surgery, were controlled through stratification. Post-stratification paired t-test and independent-sample t-test were applied using P ≤ 0.05 as significant. Results: In this study 57 patients who underwent elective craniotomy were included to assess the mean blood loss and to compare mean blood loss in patients with normal and deranged coagulation profiles. The mean age of patients included in the study was 39.36±13.94 years with 43 (75.4%) males and 14 (24.6%) females. The mean preoperative haemoglobin level amongst all patients turned out to be 14.10±3.98 gm/dl. The postoperative haemoglobin level showed a decrease with a mean of 12.68±31.98 gm/dl. Therefore the mean difference calculated between pre and post-operative haemoglobin levels turned out to be 1.42±0.99 gm/dl. Conclusion: It is to be concluded that significant change was found in preoperative and post-operative Haemoglobin levels in patients undergoing elective craniotomy. There was also a highly significant difference in blood loss between patients having a normal versus deranged coagulation profile. However, there is a need to conduct more studies using a large sample size with multiple study sites in Pakistan to validate these results.

Abstract Background Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) has been translated from English into several languages. Currently, there is no validated translation of FACT-BMT in Arabic. Here, we are reporting the first Arabic translation and validation of the FACT-BMT. Methods The study was approved by the Institutional Research Advisory Council. The Arabic translation followed the standard Functional Assessment of Chronic Illness Therapy (FACIT.org) translation methodology (with permission). Arabic FACT-BMT (50- items) was statistically validated. Cronbach’s alpha for internal consistency, Spearman’s rank correlation coefficients method for Inter-scale correlations and Principal Component Analysis for factorial construct validity was used. Results One hundred and eight consecutive relapsed /refractory lymphoma patients who underwent high dose chemotherapy and autologous stem cell transplant were enrolled. There were 68 males (63%) and 40 females (37%) with a median age of 29 years (range 14–62). After Arabic questionnaire pre-testing (Cronbach’s alpha 0.744), the study included 108 patients. Cronbach’s alpha for the entire FACT-BMT indicated an excellent internal consistency (0.90); range (0.67 to 0.91). Cronbach’s alpha for sub-groups of social (0.78), emotional (0.67) and functional wellbeing was (0.88). Cronbach’s alpha for bone marrow transplant (0.81), FACT-General (0.89), and FACT- Trial Outcome Index (TOI); (0.91) also revealed excellent internal consistency. Patients had high scores in all domains of quality of life, indicating that most patients were leading a normal life. This translation of FACT-BMT in Arabic was reviewed and approved for submission by the FACIT.org. Conclusions Our data reports the first translated, validated and approved Arabic version of FACT-BMT. This will help large numbers of Arabic speaking patients undergoing stem cell/bone marrow transplantation, across the globe.

In underground coal mines, uncontrolled accumulation of methane and fine coal dust often leads to serious incidents such as explosion. Therefore, methane and dust dispersion in underground mines is closely monitored and strictly regulated. Accordingly, significant efforts have been devoted to study methane and dust dispersion in underground mines. In this study, methane emission and dust concentration are numerically investigated using a computational fluid dynamics (CFD) approach. Various possible scenarios of underground mine configurations are evaluated. The results indicate that the presence of continuous miner adversely affects the air flow and leads to increased methane and dust concentrations. Nevertheless, it is found that such negative effect can be minimized or even neutralized by operating the scrubber fan in suction mode. In addition, it was found that the combination of scrubber fan in suction mode and brattice results in the best performance in terms of methane and dust removal from the mining face. Keywords: Dust, Methane, Mine ventilation, Mining machine

Over the last decades, the palm oil industry has been growing rapidly due to increasing demands for food, cosmetic, and hygienic products. Aside from producing palm oil, the industry generates a huge quantity of residues (dry and wet) which can be processed to produce biofuel. Driven by the necessity to find an alternative and renewable energy/fuel resources, numerous technologies have been developed and more are being developed to process oil-palm and palm-oil wastes into biofuel. To further develop these technologies, it is essential to understand the current stage of the industry and technology developments. The objective of this paper is to provide an overview of the palm oil industry, review technologies available to process oil palm and palm oil residues into biofuel, and to summarise the challenges that should be overcome for further development. The paper also discusses the research and development needs, technoeconomics, and life cycle analysis of biofuel production from oil-palm and palm-oil wastes.

Abstract A recent study of randomized controlled trials showed favorable outcomes with use of decompressive craniectomy in managing and treating uncontrolled intracranial pressures accompanied with cerebral edema due to trauma. We present the details of bicompartmental decompressive craniectomy on two patients who presented with severe head trauma of supra- and infratentorial pathologies. The surgical management techniques and long-term follow-up are discussed in detail.

Objective This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) (p = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) (p = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group (p = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group (p < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups (p = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group (p = 0.14). Conclusion The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma. [ABSTRACT FROM AUTHOR]

Background: Schwannomas are benign but clinically progressive tumors. Mostly, they present as intradural extramedullary lesions. They are quite rare in the intramedullary (IM) region. We report a case of IM schwannoma. Case Description: A 52-year-old gentleman presented with a history of gait instability and numbness in bilateral lower limbs. He had clinical signs of myelopathy. His magnetic resonance imaging (MRI) dorsal spine was done that showed an intradural IM lesion at the level of D11, with one differential of ependymoma. Near total resection of lesion was done and histopathology reported it schwannoma. Conclusion: Preoperative radiologic assessment for IM spinal lesions is difficult and high degree of suspicion should be present when approaching a patient with somatic pain and IM lesion on MRI, keeping in mind one differential of IM schwannoma. [ABSTRACT FROM AUTHOR]

Background: Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR. Methods: This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores. Results: The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups. Conclusion: RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR. [ABSTRACT FROM AUTHOR]

Background Pleomorphic xanthoastrocytoma (PXA) classified as a low Grade (WHO II) astrocytic neoplasm. It is known for its relatively favorable prognosis. It most commonly occurs in young adults. Malignant progression in PXA has been frequently reported since its first description in 1979; however, the presentation of a primary anaplastic PXA tumor with an aggressive clinical course in adults is rare especially in the later age group. Case description We present a case of primary anaplastic PXA in a 53 year old male that manifested with an early recurrence pattern at 9 weeks. Treatment performed was surgical excision and external beam radiotherapy. The aforementioned tumor followed an aggressive clinical course. Tumor cells exhibited the characteristic expression of GFAP (Glial fibrillary acidic protein), higher proliferative index (8–10%) on Ki-67 staining along with the presence of increased mitoses ( >5/10hpf). A review of previously reported primary anaplastic pleomorphic xanthoastrocytoma cases in adults with histological features was also done. Conclusion Our review of all reported cases of APXA in adults concludes that the clinical behavior of this tumor varies considerably from its benign variant. Early disease recurrence in anaplastic pleomorphic xanthoastrocytomas is associated with fatal outcomes. As per our review of literature it is seen that anaplastic variant of PXA shows histological characteristics as well as clinical course comparable with Grade III astrocytomas. We recommend further evaluation of PXA with anaplastic features regarding their genetic characteristics to understand the origin as well as behavior of this tumor. [ABSTRACT FROM AUTHOR]

Background: Ependymal tumors with oligodendroglioma like clear cells have never been reported from Pakistan. We aimed to see the features and outcomes of this rare entity. Methods: It was retrospective cohort conducted at the Department of Neurosurgery, Aga Khan University from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. Analysis was done on SPSS 20. Results: Eleven cases of ependymal tumors with clear cells were found, which equated to 1.5% of the total tumor burden in 11 years. The median age was 49 years. Most common presenting symptom was headache 54.5%. Out of 11 patients, 9 patients had a supratentorial tumor. Magnetic resonance imaging showed hypointense signals on T1 and hyperintense signals on T2weighted images in all cases. Contrast enhancement was found in 9 patients (77.8%), necrosis and hemorrhage was found in 4 (36%) and 3 (27%) patients, respectively. Immunohistochemistry showed glial fibrillary acidic protein and epithelial membrane antigen positivity in all cases. Ki67 showed high proliferative index in 6 patients. According to the World Health Organization grading of ependymal tumors, 2 patients had Grade II tumors, and 9 patients had Grade III tumors with clear cells. Gross total resection was achieved in 6 (54.5%) and subtotal resection in 5 patients (45.4%). Recurrence was observed in 9 patients. Six patients died of the disease. Median progressionfree survival and overall survival was 8 months and 10 months, respectively. Conclusion: Ependymal tumors with clear cells presented more commonly in Grade III lesions and were more aggressive in behavior with poorer outcome compared to similar studies. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify the need of nursing care in functionally dependent neurosurgical patients and to evaluate the difference in outcome of care provided by Professional Nurses (PN) and Trained Family Member (TFM). METHODS: This is retrospective cohort study conducted at Aga Khan University Hospital for period of two years (2012-2014). Forty patients met the selection criteria. They were divided into 02 groups: Group 01 taken care by TFM and group 02 by PN. Data regarding demographics including age, mode of injury, severity of head injury, radiological findings, procedure performed and Glascow Outcome Score (GOS) at discharge and followup was documented. Patient requiring nursing care were identified by the primary attending or the patient care coordinator (PCC) and was placed either in one of the groups according to their desire/financial status. Nursing needs were identified for each patient and care givers were assessed for providing these nursing needs by PCC. Outcomes assessed included mortality, GOS, new bed sore development and time to de-canulate. Patients were followed for a median follow-up of one year. Data was collected on structured Performa and analysis was performed on SPSS version 22. Descriptive analysis, including means and standard deviation for continuous data with normal distribution and median (range) for skewed data was done. Chi-square test was use to compare categorical data and Student T-test for numerical data. Significance of p< 0.05 is taken as significant. RESULTS: Forty patients were included in this study. Twenty three patients were taken- care by trained family member while seventeen were managed by professional nurse. The mean age of patients taken care by trained family members was 34.65±17.43 years while mean of professional nurse group was 44.27±17.24. Mode of injury, severity of head injury, injury on CT scan, procedure performed and GOS (at discharge) were comparable among the two groups. Eighteen patients had undergone tracheostomy nine in each group requiring tracheostomy care. PN handled nine PEG tubes while TFM managed four PEG tubes. Log Rolling was identified as nursing need of 29 patients including seventeen in PN and twelve in TFM. PN managed care of 6 PICC line while TFM. The nursing requirements among the two groups were also found to be comparable. Outcomes assessed between the two groups included GOS (At median follow-up of 1 year) which showed better outcome in PN group but was not statistically significant. Similarly on follow-up nine patients taken care by TFM had develop new bed sores while only three bed sores were present in PN. Out of eighteen patients with tracheostomy only nine got de-canulated with majority six in PN group. Seven patients expired on follow-up with five patients in the TFM group. Outcomes assessed between the two groups including median time to decanulation, bed sore development, GOS and mortality though showed better outcome in PN group but did not show any statistical significance. CONCLUSION: In our study it was observed that patient taken care by PN, seems to have better outcomes though not satisfactorily significant which could be due to small sample size. Prospective studies with larger sample size are required. [ABSTRACT FROM AUTHOR]

BACKGROUND: Postoperative meningitis is a growing cause of concern especially with the evolution of multidrug resistant organism. OBJECTIVES: The authors evaluate the use of intraventricular/intrathecal antibiotics for postoperative Gramnegative meningitis in patients whom intravenous antibiotics were ineffective METHODS: Adult consecutive patients with cerebrospinal fluid (CSF) culture proven Gram-negative postoperative meningitis/ventriculitis, in which intravenous antibiotics were ineffective were included from January 2008- December 2012. RESULTS: From January 2008 to December 2012 there were 94 reported cases of post-operative meningitis/ventriculitis at our institution. Of these, 63 were culture proven Gram positive and were treated accordingly. Thirty one patients either had isolated Gram negative meningitis/ventriculitis or mixed Gram positive/negative, infection, of which 21 patients required treatment with IVT/IT antibiotics. Of these 21 patients, 16 were male and 5 were female. Mean age was 41.7 + 11 years (range 26 to 58 years). All except one of these patients had cranial surgery. Of the 21 patients in our study, 8 were admitted with a GCS of >12 while the remaining had a GCS < 12. Acinetobacter was the most common organism isolated on CSF culture (n=14) followed by Klebsiella (n=3), Pseudomonas (n=1) and Enterobacter (n=1). 1 patient had polymicrobial growth. Three antibiotics were used in the IVT/IT treatment group; Amikacin, Polymixin B and Colistin. The indication was primarily based on the sensitivity of pathogenic organisms cultured on CSF of individual patients; table 2 shows the resistance pattern of the organism. Amikacin was used in 7 patients, Polymixin B in 9 patients and Colistin in 5 patients. A combination of 2 IVT/IT antibiotics, Polymixin B and Amikacin was used in 1 patient. An EVD was used as the route of administration in 13 cases (62%) while a lumbar drain was used in 8 (38%) patients. Median duration between starting of IT/IVT after being diagnosed with post neurosurgical meningitis/ventriculitis was 3 days (Range 0-7days). Median duration of IVT/IT therapy was 15 (9-25) days. CSF sterility was achieved in all of the patients with a median time to sterility being 7.1 + 3.8 (Range 2-16) days (EVD 7.08 + 3.37 days vs. LD 7.1 + 4.6 days, p-value 0.176). Only two patients achieved CSF sterility within 48 hours. RESULTS: Discharge GCS improved in 2 remained the same in 7 and deteriorated in 12 patients. Median hospital stay was 38 days (20-257days) with the EVD group [46 (29-72)] having a longer stay than LD group [32.5 (20-76) days) p-value 0.07. At 6 months follow up favorable outcomes were seen in 14 (66.7%) patients and 7 (33.3%) patients remained in an unfavorable state. One patient died during treatment and although the patient had Acinetobacter species infection, the cause of death was found to be a massive pulmonary embolus. No adverse effects attributable to IVT/IT therapy were noted in the study. CONCLUSION: The findings of this study suggest that IVT antibiotic therapy is a useful option especially in patients who are non-responsive to standard intravenous therapy with little or no side effects. [ABSTRACT FROM AUTHOR]