The medial plantar artery flap: A series of cases over 14 years

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga KhanUniversity and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity

POTENTIAL OF TURMERIC EXTRACT AND ITS FRACTIONS TO CONTROL PEACH FRUIT FLY (DIPTERA: TEPHRITIDAE)

ABSTRACT Potential of turmeric extract and its chemical fractions were evaluated to control the infestation of Bactrocera zonata peach fruit fly in a mortality-based bioassay. The turmeric extract (TE) was taken on Soxhelt's extraction apparatus and chemically fractioned by thin layer followed by column chromatography into 6 fractions (F1 ...F6). Fifty pairs of the flies were fed in cages with 250 and 500 ppm TE and its fractions separately for 20 days along with flies fed on untreated diet to serve as control. The toxicity of TE and each of its fractions was evaluated by calculating percent mortality of fly population after every 5th day in 4 consecutive intervals. Mortality of fly population was observed to be positively correlated with increasing concentrations of TE and its fractions in diet. The mortality of flies fed at 250 and 500 ppm TE was significantly higher at 44.17 and 66.33% compared to 28.88% in control. Percent mortality was much higher in case of flies fed with fractions F1, F3 and F6 i.e. 72.22, 50.00 and 48.76 respectively. Maximum rise of mortality was observed at the end of 3rd interval; in case of flies fed at 500 ppm TE, 52.45 percent mortality was observed at the end of 3rd interval; highest mortality was caused by fraction F1, 51.39% in case of flies fed at 250 ppm and 70.37% in case of those fed at 500 ppm

Pakistan Brain Tumour Epidemiology Study (PBTES): Uncovering the Hidden Burden of Brain Tumours in the Country

Epidemiological studies have significantly helped determine the burden, types, and geographical distribution of brain tumours in HICs (highincome countries). However, brain tumour data from low-and-middle-income countries is often sparse, focusing on a few centres1. The situation in Pakistan is no different. Few oncological registries exist in our region that focus on common tumours. Collecting data regarding brain tumours has been challenging, as evidenced by the underreported incidence of brain tumours by centers such as the Karachi Cancer Registry (KCR), Pakistan Atomic Energy Commission (PAEC) report, and GLOBOCAN. Brain tumours are distinct from other cancer types by having more than 200 subtypes, requiring complex analysis, grading, and personalized therapeutic strategies. Moreover, there is no current standardized system to record brain tumour patient data, making it difficult to collate data from various centers. Continue

Are rural hospitals in Pakistan responding to the global surgery movement? An analysis of the gaps, challenges and opportunities

Background: Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan.Methods: This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool.Results: This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population.Conclusions: Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention

Treatment patterns of glioma in Pakistan: An epidemiological perspective

Objective: To define the landscape of treatment patterns and current epidemiological data regarding gliomas in Pakistan. Methods: As part of the Pakistan Brain Tumour Epidemiology Study (PBTES), data were collected from 32 neurosurgical centres across the country. Our retrospective study looked at patients who underwent surgical procedures for gliomas in 2019 in neurosurgical centres. The data was collated and analysed using STATA          version 15. Results: A total of 781 patients with gliomas were identified 479(61.8%) in public sector hospitals, 302(39.1%) in the private sector). The most common histopathological subtypes were glioblastoma 262 (33.5%), followed by astrocytoma 147(18.8%) and oligodendroglioma 93(11.9%). Gender distribution was skewed towards men 508(65%). Private institution hospitals performed surgical biopsies as the first surgical procedure 75(23%) more often than public hospitals 38(9%). Chemotherapy was given to 115(29.8%) patients, and there was no data regarding 467(53%) of patients. Similarly, only 202(43.9%) patients received radiation therapy, and there was no data for 469(60%) of patients. For high-grade gliomas specifically, only 95(31.8%) patients with HGG have a record of receiving radiation therapy, and only 57(18.9%) had a record of being started on chemotherapy. Conclusions: Our study highlighted gaps in glioma management within Pakistan, with only around half of our patients receiving chemotherapy and radiotherapy, despite it being indicated. In our experience, high-grade tumours were diagnosed at a younger age than in high-income countries, but overall, glioblastoma was a smaller constituent of our tumour sample than expected. Keywords: Glioblastoma. Oligodendroglioma, Glioma, Astrocytoma, Brain Neoplasms, Registries, Epidemiology. Continue..

Characteristics of highly cited articles in heart failure: a bibliometric analysis

Despite a vast array of research in heart failure (HF), no bibliometric analysis has been conducted for HF. Therefore, we sought to identify in-depth characteristics of 100 most cited publications in HF. Two independent reviewers searched the Scopus Library Database using a variety of keywords to extract the top 100 articles. Majority (36%) of top 100 cited articles were published between 2001 and 2005. The total number of citations ranged from 6294 to 1003. Females had less than a quarter representation in both first and senior author position. More than three-fourths (86%) of the articles were funded. Our analysis highlights focal areas of research activity in order to guide HF specialists toward impactful research areas

Time to surgery after radiological diagnosis of brain tumours in Pakistan: A nationwide cross-sectional study

Objective: To investigate waiting times for brain tumour surgery in Pakistan from a nationwide sample and highlight specific affected patient populations. Methods: A nationwide study was conducted as part of the Pakistan Brain Tumour Epidemiology Study; data from 32 high-volume neurosurgical centres were collected. The national sample included 2,750 patients. Time to surgery was calculated by the difference in dates recorded for radiological diagnosis and the date of the first surgery. This was further stratified according to demographic factors, histopathological diagnosis, type of surgical procedure performed and survival outcomes. Results: The data of 1,474 patients for time to surgery was available. Patients travelling to public hospitals had significantly longer mean wait times (94.07 (CI: 85.29, 102.84)  vs 75.14 (CI: 54.72, 95.56) days, p<0.001). Significant differences were seen between patients of various age groups, as adolescents (116.63 (CI: 65.27, 167.98) days) and young adults (103.34 (CI: 85.96, 120.72) days) had higher waiting times compared to middle-aged (72.44 (CI: 61.26, 83.61) days) and older (48.58 (CI: 31.17, 65.98) days) adults. No difference was seen between the genders. A significantly longer time to surgery was observed for middle- and lower-socioeconomic class patients. Those undergoing gross total resection of the tumour had significantly (p<0.001) longer waiting times for surgery when compared to STR (sub-total resection), biopsy, and CSF-diversion procedures, for all tumour types.  Patients diagnosed with meningioma had the most prolonged waiting periods (106 (CI: 76, 95) days). Gliomas had a mean waiting period of 88 (CI: 73, 103) days across the country. Low-grade gliomas had significantly (p=0.031) longer mean waiting times (99.73 (CI: 61.91, 127.36) days) in comparison to high-grade gliomas (70.13 (CI: 43.39, 89.69 ) days). A significant difference was seen between waiting times for patients who survived surgical procedures for a brain tumour on the most recent follow-up and those who had expired (91.87 (CI: 79, 107.74)  vs 77.41 (CI: 59.90, 94.91)  days, p<0.001). Conclusion: Prolonged delays to surgery are a significant barrier within low-and-middle-income countries, leading to adverse outcomes for patients. Patients undergoing brain tumour surgery at public hospitals from lower or middle SES and electing for gross resections were more likely to have longer delays. Keywords: Treatment delay, Neuro-oncology, Time to surgery, Neurosurgery

Prioritizing Pituitary Adenoma Care in Pakistan: Analysis from an Epidemiological Study

Objective: To identify symptoms and risk factors and promptly diagnose, treat, and manage pituitary adenomas. Prioritizing care for pituitary adenomas will reduce the prolonged disability. Methods: Patients with a histopathological diagnosis of a pituitary adenoma that presented at 32 tertiary care neurosurgical centres were included. The information recorded included demographics, treatment methods, adjuvant chemoradiotherapy and loss to follow-up. Data on tumour size, functionality, and laterality were collected. Results: Of the 32 hospitals surveyed, 24 operated on pituitary adenomas, and treated 277 patients. The mean age at diagnosis was 39.8 ± 13 years, with a majority of males (63.5%) being diagnosed than females. Paediatric cases constituted only 4.7% of the total pituitary adenomas operated upon. Gross total resection was reported for 155 (56%) of all pituitary adenoma patients. Majority of the patients affected by pituitary adenomas (80.1%) were from the working class. Conclusion: Highlighting care for non-malignant brain tumours is important for Pakistan's health system. Evidence pertaining to gender and age disparities indicates that males in the younger age groups are predominantly affected, which takes a large socio-economic toll on patients and their households. This study also highlights the need to incorporate digital health technologies for postoperative follow-up and adjuvant treatment. Keywords: Pituitary Neoplasms, Chemoradiotherapy, Healthcare, Socioeconomic Factors, Demography. Continue..

Craniopharyngioma: A lower-middle-income-country epidemiology

Objective: To quantify the frequency of craniopharyngiomas presenting to tertiary care neurosurgical centres, the demographics and mortality rate, and commonly presenting to neurosurgical practice. Methods: Our study was a retrospective cross-sectional analysis of patients admitted at 32 neurosurgical centres between January 1, 2019, and December 31, 2019, with brain tumour. Kruskal Wallis analysis was used to determine normality; normally distributed variables were reported as means with standard deviation, while median with interquartile range was used for non-normally distributed variables. Results: Of 2750 patients with brain tumours, 114 patients presented with craniopharyngioma. The median age at diagnosis was 18 years, with 42 (42.8%) patients below the age of 15, 40 (40.9%) patients aged 15-39, and 16 (16.3%) patients aged 40 and above. There were 70 (61.4%) males and 44 (38.6%) females in our cohort. Gross total resection was performed in 42(36.8%), 45 (39.5%) underwent subtotal resection, 9 (7.9%) underwent CSF diversion only, and 2 (1.8%) had a biopsy. Most of our patients 94(82.5%) presented to public hospitals, with 20 (17.5%) patients presenting to private hospitals (p=0.002). The overall survival at two years was 86.8% in patients with known outcomes, and only 10% of patients died within 30 days of surgery. Conclusion: Craniopharyngiomas comprised a small portion of all brain tumours in our region. They are more common in males and in patients from the lower socioeconomic class. These patients mainly presented to public sector hospitals, and the three highest volume centres were all public sector institutions. The overall survival rate at two years in our region is lower than in other regions. Keywords: Craniopharyngioma, Brain neoplasm, Retrospective study, Epidemiology, LMIC. Continue..