Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S

Introduction

Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant.

Methods

We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints.

Results

A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three.

Discussion

The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

722 IMPLEMENTATION OF TREATMENT ESCALATION PLANS IN A COMMUNITY PSYCHIATRIC HOSPITAL

Introduction

Treatment Escalation Plans (TEP) detail appropriate ceilings of care and guide treatment of patients based on shared decision making. Whilst established in many acute trusts, TEP are not frequently used in community mental health hospitals. This is particularly concerning in organic mental health wards, where patients with severe dementia may be transferred to acute hospitals for treatment without consideration about whether this is appropriate. This quality improvement project aimed to develop and implement TEP within a community mental health hospital to support the management of our older patients with severe mental illness.

Methods

We designed a TEP form based on a prototype used in a partner acute trust and evaluated its use on our wards, comprising 20 patients between August–September 2020. We obtained quantitative data on use of TEP, including the length of time from admission to completion, as well as qualitative data from healthcare staff regarding their experience of using TEP.

Results

TEP implementation well received among members of staff. 100% of patients had a TEP in place within 2 weeks of admission. The mean time taken to complete a TEP was reduced from 7.1 days to 3.2 days following inclusion of the TEP proforma in admission packs. There was an improvement in understanding the purpose, comprehensiveness and location of TEP forms during their implementation. The key theme that arose from qualitative analysis of healthcare staff comments was that TEP forms provided clear guidance on appropriateness of escalation of care.

Conclusion

TEP forms offer clear guidance to treating clinicians about the ceilings of care for patients. TEP were successfully implemented in our community mental health hospital and we plan further post-implementation evaluation. We intend to roll out the TEP form across our mental health trust and share findings nationally to promote best practice.

Impact of COVID-19 on the Children with Cancer in 6 Pediatric Oncology Units (POU's) of Pakistan-a Multi-Center Study

The study is to evaluate the impact of COVID-19 in Pediatric Oncology Units of Pakistan. Data from (1 April-30 June) 2019 and (1April-30 June) 2020 for 1^st and 2^nd cohort respectively in order to compare the registration, abandonment rate and delay in treatment. 634 were registered cases, 379 and 255 in 1^st and 2^nd cohort respectively which was significant different <0.005. 77 were abandoned, 45 and 32 in 1^st and 2^nd cohort respectively. 59 COVID-19 positive cases, 24, 4, 27 and 4 were admitted, referred, home isolated and LAMA respectively. Delayed in treatment and reduction in new cases were observed.

Upfront Nephrectomy Versus Preoperative Chemotherapy In Wilm's Tumour

BACKGROUND

Wilms tumour is the most common renal tumour in paediatric age group. This study was done to compare the two approaches used for treatment, namely upfront nephrectomy versus pre-operative chemotherapy..

METHODS

A descriptive cross-sectional study was done enrolling all the patients of Wilms tumour reporting to Oncology unit Children's Hospital during the study period. A total of 80 patients were divided into 2 groups. One group (n=40) had upfront surgery while the other (n=40) received pre-op chemotherapy before surgery. Both groups were compared for outcomes including whether treatment completed and declared cured, lost during treatment against medical advice, or died during treatment.

RESULTS

It was found that stage 2 patients were more likely to get upfront surgery done while stage 3, 4 and 5 were likely to get pre-operative chemotherapy before nephrectomy. Also, favourable histology was associated with better outcome overall outcome.

Posterior sagittal approach for resection of sacrococcygeal teratomas

The aim is to evaluate the ease of access, surgical trauma and cosmetic results of posterior sagittal approach for sacrococygeal teratomas (SCTs). From January 2002 to June 2010, we operated 19 cases of SCT exclusively through posterior sagittal approach. Patients were placed in knee chest position. An elliptical incision was made for the excision of the tumor. Care was taken to preserve all the muscles and other vital tissue in this area. Coccygectomy was performed in all patients. Closure was performed in layers. It was possible to resect all tumors from this approach and none of the patients required revision of the incision. Complete resection was possible in 17 patients while two had residual disease due to local extension. Minimal wound dehiscence was noted in four patients that healed spontaneously. It was possible to perform excision even in very large masses. Wound scar was satisfactory in most patients with preservation of gluteal folds. It is therefore concluded that posterior sagittal approach for SCT is feasible, with good access and cosmetic results.

Childhood acute lymphoblastic leukaemia; epidemiology and clinicopathological features

OBJECTIVE

To study epidemiology, clinical presentation and laboratory features of childhood Acute Lymphoblastic Leukaemia.

METHOD

This retrospective review included all newly diagnosed children with acute lymphoblastic Leukaemia less than 15 years of age registered from April 1999 to December 2004 at oncology unit of National Institute of Child Health and Children Cancer Hospital, Karachi. The objective was to look for epidemiological data, the clinical features and laboratory findings at presentation and compare it with reported literature.

RESULTS

Acute lymphoblastic Leukaemia constituted 32% (611 /1890) of all cancers in this study. Majority of patients hailed from Karachi (59%) and interior Sindh (27%) while rest from other parts of country. Patient's referral increased over the years, from 42 in 1999 to 127 in 2004. The age ranged between 3 months to 15 years with a median age of 6.5 years. Male to female ratio was 1.7:1 Family history of cancer was present in 5% of patients. Fever and pallor were the commonest presenting features. Anaemia (86%), lymphadenopathy (75%) hepatomegaly (67%) and splenomegly (58%) were common findings on physical examination. Initial high white cell count (> 50,000) was observed in 34% patients. Haemoglobin < 7gm/dl was seen in 54% and Platelet counts less than 20,000 was observed in 33% cases. CNS disease was present in 5% and HBsAg was positive in 14% patients at diagnosis.

CONCLUSION

Acute Lymphoblastic Leukaemia accounts for one third of total registered cases. Age distribution in this series shows less prominemt early peak and more significant late peak and a median age of 6 years. Consangunity was found in 47% cases. The fraction with a WBC count above 50,000 mm3 (30%), a higher proportion with lymphadenopathy (75%) and haemoglobin less than 7 gm/dl (54%) suggest that Pakistani children have significantly higher burdens of Leukaemia cells at presentation. These may have prognostic implication resulting in poor outcome of Leukaemia in this part of the world.

Spectrum of common childhood skin diseases: a single centre experience

OBJECTIVE

To assess the pattern of childhood skin diseases and to analyze the attitude towards consultation and self-treatment.

METHODS

Children with complaints of skin diseases visiting outpatient department of Jinnah Postgraduate Medical Centre and National Institute of Child Health were enrolled in this study during the period of May 2002 to July 2003. A detail performa was filled in, for all the patients. 250 cases were finally analyzed in 15 months duration. The diseases were sub-classified on etiological basis e.g. infectious (bacterial, fungal, viral, parasitic) immune mediated, congenital, allergic and miscellaneous. The children's sex, race, age, duration, history of previous treatment and family and past history for skin or systemic diseases were noted.

RESULTS

Of all the patients visiting the outpatient department (OPD), 31% were children with skin diseases. Infectious skin diseases were the commonest (60%). Among the infections, fungal were maximum (20.6%), followed by bacterial diseases (12%). Eczemas constituted 21% of skin diseases and 6.4% children had congenital skin conditions. Previous treatment history was present in 43.6% patients. Antibiotics (topical and/or systemic) were taken by 28.4% of patients; whereas history of steroids (topical and/or systemic) was present in 15.2% of patients. Most children (550) had a normal weight and 13.6% were severely malnourished.

CONCLUSION

Skin diseases are fairly common in children especially infectious skin diseases. Eczematous and allergic skin diseases are also frequently encountered in children. Self medication is a common practice. Topical steroids were the most commonly used medications.

Cutaneous tuberculosis: a three year prospective study

OBJECTIVE

To study the pattern of clinical presentation of cutaneous tuberculosis.

METHODS

All patients with clinical suspicion of cutaneous tuberculosis, visiting outpatient department of Dermatology Unit, Jinnah Postgraduate Medical Centre, Karachi were included in this study. Total number of the patients enrolled were 74. The lesions were then classified into four clinical types viz: lupus vulgaris, scrofuloderma, tuberculids and tuberculosis verricosa cutis.

RESULTS

A total of 0.1% patients visiting out patient department had cutaneous tuberculosis. Scrofuloderma was the commonest form seen in 48 (64.9%) patients, followed by lupus vulgaris in 16 (21.5%), tuberculosis verrucosa cutis in 6 (8.1%) and tuberculids 4(5.6 %). The presence of regional lymphadenopathy had correlation with the disseminated disease.

CONCLUSION

There is an increasing trend of cutaneous Tuberculosis over the years. Scrofuloderma was the most common clinical presentation, followed by lupus vulgaris, tuberculosis verrucsa cutis and tuberculids. Tuberculous gumma was not seen in any patient.

Insecticide induced disruptions in functioning of developing brain of Rana cyanophlictis

Synthetic pyrethroid insecticide permethrin significantly decreased the levels of regulatory proteins (S-100 and calmodulin) in the developing CNS of tadpoles of R. cyanophlictis. Remarkable inhibition of enzymes acetylcholinesterase and choline acetylase and significant accumulation of neurotransmitter acetylcholine were observed in permethrin treated animals. Permethrin exposure significantly decreased the activity of phosphodiesterase. The results support molecular disruptions occurring due to permethrin induced toxicity. This in turn may bring about neuronal inefficiency in the treated tadpoles.