Ameloblastoma : Management and outcome

Introduction Ameloblastoma is a locally destructive tumor with a propensity for recurrence if not entirely excised. Management of ameloblastoma poses a challenge for all involved in the field of head and neck surgery because successful treatment requires not only adequate resection but also a functional and aesthetically acceptable reconstruction of the residual defect. Methods Patients who had histologically proven ameloblastoma between 1991 and 2009 were identified from the database of Aga Khan University Hospital. A review of all medical records, radiological images, operative reports and pathology reports was undertaken. Results A total of 15 patients with histologically confirmed ameloblastoma were identified. Out of 15 patients nine were males and six were females with age range from 20 to 60 years (mean age 43 years). The most common symptom found in our patient group was painless facial swelling. In 13 patients the origin of tumor was mandible and in the remaining two the tumor originated from maxilla. Eleven out of 15 patients underwent segmental mandibulectomy, two had maxillectomy and two had enucleation. All patients who underwent segmental mandibulectomy required reconstruction. Reconstruction was done with microsurgical free tissue transfer in eight patients, non-vascularized iliac crest bone graft was used in one patient and two had plating only. All free flaps survived with no evidence of flap loss. The mean follow-up was eight years. There was no evidence of graft failure which was used in one patient. Complication was seen in only one of our patients in the form of plate exposure. Recurrence was seen in two of our cases who primarily underwent enucleation. All patients had satisfactory speech, cosmesis and mastication. Conclusion The management of ameloblastoma still poses a big challenge in spite of being the most common odontogenic tumor. In our study we have found that segmental mandibulectomy with disease-free margin of around 1 cm and immediate reconstruction with free tissue transfer have shown good results

Robust, Resilient and Reliable Architecture for V2X Communication

The new developments in mobile edge computing (MEC) and vehicle-to-everything (V2X) communications has positioned 5G and beyond in a strong position to answer the market need towards future emerging intelligent transportation systems and smart city applications. The major attractive features of V2X communication is the inherent ability to adapt to any type of network, device, or data, and to ensure robustness, resilience and reliability of the network, which is challenging to realize. In this work, we propose to drive these further these features by proposing a novel robust, resilient and reliable architecture for V2X communication based on harnessing MEC and blockchain technology. A three stage computing service is proposed. Firstly, a hierarchcial computing architecture is deployed spanning over the vehicular network that constitutes cloud computing (CC), edge computing (EC), fog computing (FC) nodes. The resources and data bases can migrate from the high capacity cloud services (furthest away from the individual node of the network) to the edge (medium) and low level fog node, according to computing service requirements. Secondly, the resource allocation filters the data according to its significance, and rank the nodes according to their usability, and selects the network technology according to their physical channel characteristics. Thirdly, we propose a blockchain-based transaction service that ensures reliability. We discussed two use cases for experimental analysis, plug- in electric vehicles in smart grid scenarios, and massive IoT data services for autonomous cars. The results show that car connectivity prediction is accurate 98% of the times, where 92% more data blocks are added using micro-blockchain solution compared to the public blockchain, where it is able to reduce the time to sign and compute the proof-of-work (PoW), and deliver a low-overhead Proof-of-Stake (PoS) consensus mechanism. This approach can be considered a strong candidate architecture for future V2X, and with more general application for everything- to-everything (X2X) communications

Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding.

Aim: To study the prevalence, predictors and control of bleeding following N-butyl 2 cyanoacrylate (NBC) sclerotherapy of gastric varix (GV). Methods: We analyzed case records of 1436 patients with portal hypertension, who underwent endoscopy during the past five years for variceal screening or upper gastrointestinal (GI) bleeding. Fifty patients with bleeding GV underwent sclerotherapy with a mean of 2 mL NBC for control of bleeding. Outcome parameters were primary hemostasis (bleeding control within the first 48 h), recurrent bleeding (after 48 h of esophagogastro-duodenoscopy) and in-hospital mortality were analyzed. Results: The prevalence of GV in patients with portal hypertension was 15% (220/1436) and the incidence of bleeding was 22.7% (50/220). Out of the 50 bleeding GV patients, isolated gastric varices (IGV-I) were seen in 22 (44%), gastro-oesophageal varices (GOV) on lesser curvature (GOV-Ⅰ) in 16 (32%), and GOV on greater curvature (GOV-Ⅱ) in 15 (30%). IGV-Ⅰ was seen in 44% (22/50) patients who had bleeding as compared to 23% (39/170) who did not have bleeding (P \u3c 0.003). Primary hemostasis was achieved with NBC in all patients. Re-bleeding occurred in 7 (14%) patients after 48 h of initial sclerotherapy. Secondary hemostasis was achieved with repeat NBC sclerotherapy in 4/7 (57%). Three patients died after repeat sclerotherapy, one during transjugular intrahepatic portosystemic stem shunt (TIPSS), one during surgery and one due to uncontrolled bleeding. Treatment failure-related mortality rate was 6% (3/50). Conclusion: GV can be seen in 15% of patients with f patients with using the tissue adhesive agent butyl cyanoacrylate. Since then several authors have used different sclerosing agents to achieve hemostasis in bleeding gastric varices, including N-butyl-2 cyanoacrylate (histoacryl)[4,8], 2-octyl cyanoacrylate[9], ethanolamine oleate injection[10], gastric variceal banding[11], thrombin[12], sodium tetradecyl sulfate[13]. However, N-butyl 2 cyanoacrylate (NBC) is the only promising agent. Most reports on endoscopic treatment of bleeding gastric varices are small series, case reports, or retrospective reviews[14,15]. Not more than 1000 patients with bleeding GV have been treated with different sclerosing and coagulating agents. Cyanoacrylate injection can achieve primary hemostasis in 70% to 95% of patients with acute GV bleeding, with an early rebleeding rate ranging from 0% to 28% within 48 h[5,7,16]. Different doses of cyanoacrylate are used by different gastroenterologis ts[16,17]. Moreover, dilution ratio of NBC to lipoidal is different[18,19]. However, there is no consensus regarding effective dose and dilution of sclerosing agents. This study was to analyze patients with GV in order to establish predictors of bleeding GV, and the efficacy and safety of NBC in treatment of bleeding GV

Mutational landscape of head and neck squamous cell carcinomas in a South Asian population

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer type globally and contributes significantly to burden of disease in South Asia. In Pakistan, HNSCC is anmong the most commonly diagnosed cancer in males and females. The increasing regional burden of HNSCC along with a unique set of risk factors merited a deeper investigation of the disease at the genomic level. Whole exome sequencing of HNSCC samples and matched normal genomic DNA (n=7) was performed. Significant somatic single nucleotide variants (SNVs) were identified and pathway analysis performed to determine frequently affected signaling pathways. We identified significant, novel recurrent mutations in ASNS (asparagine synthetase) that may affect substrate binding, and variants in driver genes including TP53, PIK3CA, FGFR2, ARID2, MLL3, MYC and ALK. Using the IntOGen platform, we identified MAP kinase, cell cycle, actin cytoskeleton regulation, PI3K-Akt signaling and other pathways in cancer as affected in the samples. This data is the first of its kind from the Pakistani population. The results of this study can guide a better mechanistic understanding of HNSCC in the population, ultimately contributing new, rational therapeutic targets for the treatment of the disease

Resilience and quality of life (QoL) of head and neck cancer and brain tumour survivors in Pakistan: An analytical cross-sectional study protocol

Background: Cancer is a devastating disease and has detrimental effects on the quality of life (QoL) of cancer survivors and interferes with their treatment compliance. The aim of the study is to assess resilience and QoL among cancer survivors and to evaluate the important factors affecting their resilience and QoL, with respect to the Pakistani cultural context.Method and Analysis: A cross-sectional study will be conducted at a tertiary care hospital in Karachi, Pakistan. A minimum sample size of 250 head and neck cancers and 250 brain tumour survivors with 10% inflation for non-response rate will be required. The SD of QoL and resilience will range from 16.5 to 40.8 for head and neck cancer, and 12.7 to 34.1 for brain tumour, at 5% level of significance, with 2.5 precision. QoL will be assessed by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-H&N35 and EORTC QLQ-BN20 and resilience will be evaluated by Wagnild and Young\u27s 14-item scale. Mean±SD will be reported for resilience and QoL scores. Unadjusted and adjusted β-coefficients, with 95% CI, will be reported by using multiple linear regression analysis. Correlation analysis will also be performed using Pearson or Spearman rank correlation coefficients. A p value of \u3c0.05 will be considered significant.Ethics and Dissemination: Ethical approval has been obtained from the Aga Khan University Pakistan\u27s Ethical Review Committee. Written informed consent will be taken from the participants by trained research assistants. A trained psychologist will provide on-spot counselling to the participants and those identified with severe depression will be referred to a psychiatrist. The study materials will be kept under lock and key and the electronic data base will be password protected and will only be accessed by the research team. The study findings will be disseminated through publications conferences and workshops and research briefs

Successful management of aggressive fibromatosis of the neck using wide surgical excision: a case report

<p>Abstract</p> <p>Introduction</p> <p>Aggressive fibromatosis is a benign tumor, thought to arise from deep musculoaponeurotic structures, rarely found in the head or neck. However, when it does occur in the head and neck region, it tends to be more aggressive and associated with significant morbidity, which may be attributed to the vital vascular, neurological or anatomical structures in close proximity.</p> <p>Case presentation</p> <p>We report the case of a 39-year-old Pakistani man who presented with a two-month history of a lump on the right side of his neck. The mass was excised and histopathological analysis revealed a case of aggressive fibromatosis.</p> <p>Conclusion</p> <p>Due to the rarity of the condition no guidelines are available on the indications and extent of each modality. Due to its aggressive behavior and tendency to invade local structures and recur, a multi-modality management strategy is usually employed. On the basis of this case, we suggest that aggressive surgery is a viable management option and may be successfully used as a single modality treatment.</p

Understanding communication pathways to foster community engagement for health improvement in North West Pakistan

Background: This paper describes the community engagement process undertaken to ascertain the focus, development and implementation of an intervention to improve iodised salt consumption in rural communities in North West Pakistan. The Jirga is a traditional informal structure, which gathers men respected within their community and acts in a governing and decision making capacity in the Pukhtoon culture. The Jirga system had a dual purpose for the study; to access men from the community to discuss the importance of iodised salt, and as an engagement process for the intervention. Methods: A number of qualitative data collection activities were undertaken, with Jirga members and their wives, male and female outreach workers and two groups of women, under and over forty years old. The aim of these were to highlight the communication channels and levers of influence on health behaviour, which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement. Results: Communication channels are described within local families and the communities around them. The key influential role of the Jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies. Engaging Jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community. Gendered decision making-processes within the household have been highlighted as restricting women’s autonomy. Whilst in one respect our data confirm this, a more complex hierarchy of decisional power has been highlighted, whereby the concept of ‘wisdom’, an amalgamation of age, experience and education, presents important possibilities. Community members with the least autonomy are the youngest uneducated females, who rely on a web of socially and culturally determined ways to influence decision-making. Conclusions: The major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement. The process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study

Cultural adaptation and psychometric validation of the Pregnancy Experience Scale-Brief version (PES-Brief) in Pakistani women with antenatal anxiety symptoms.

BackgroundPregnancy experiences influence fetal and birth outcomes. There is scarcity of locally validated tools to assess pregnancy experiences. We aimed to validate the Pregnancy Experience Scale-Brief (PES-Brief) in pregnant Pakistani women with anxiety symptoms.MethodsA two-step process was used including 1) adaptation via translation/back-translation followed by cognitive interviewing with 10 participants and 2) factor analysis and validation with 605 women in Rawalpindi Pakistan who had mild-moderate symptoms of anxiety, attended the antenatal clinic, and were ≤22 weeks of gestation and ≥18 years old. We calculated internal consistency and reliability and conducted exploratory and confirmatory factor analyses.ResultsCultural adaptation led to inclusion of one item of the hassles subscale and exclusion of one item in the uplifts subscale, resulting in 9 uplifts and 11 hassles. Exploratory factor analysis supported a two-factor structure, with the adapted items exhibiting loading values of ≥0.24 for their respective factors. Internal consistency was demonstrated for uplifts (Cronbach's alpha = 0.89) and hassles (Cronbach's alpha = 0.85) subscales. Uplift intensity was moderately correlated with the Hospital Anxiety and Depression Scale anxiety subscale (r = 0.54, 95% CI:0.30-0.77).ConclusionThe Urdu PES-Brief is a reliable and valid tool for use in Pakistani pregnant women with antenatal anxiety. Future studies on its validity are needed on women without symptoms anxiety