Breast cancer in a teenage girl with BRCA mutation: A case report from a low middle-income country

Introduction
A staggering majority of pediatric breast masses are benign (mostly fibroadenoma) and so a biopsy is not readily performed as it can potentially lead to a future breast disfigurement. However, this should not be standard practice as this can lead to a delayed diagnosis, and hence, the treatment of pediatric breast cancer (BC); this was also seen in our patient’s scenario.

Case history
Here, we report the case of the youngest known breast cancer patient in Pakistan, a 15-year-old girl. The right-sided breast lump which was diagnosed clinically as a fibroadenoma later turned out to be stage IIb pT3N0M0 metaplastic breast carcinoma with BRCA1 positivity and mutations in SMARCA4. Being young and unmarried, the patient and her family decided to opt for breast-conserving surgery with high-risk surveillance for breast and ovaries.

Discussion
We believe that prophylactic surgeries can be delayed with strict surveillance and thorough counseling. As pediatric BC is linked to a less favorable prognosis, every young patient diagnosed with breast cancer and their family should undergo genetic testing. BC management should be handled by specialists in the field and doctors should be trained for initial diagnostics and timely referral of patients.

Conclusion
It is important to improve our understanding of genetic predisposition and testing in lower-middle-income countries. Considering the changing global trends, we suggest that the utilization of genetic services is direly needed to improve preventative care for at-risk individuals with breast and other cancers.

Management of Congenital Heart Disease in Low-Income Countries: The Challenges and the Way Forward

In this article, we will discuss the management of congenital heart disease in low-income and low-middle income countries. First, we will review the epidemiology of congenital heart disease in the low-income and low-middle income countries and compare it to that in the high-income countries; cardiac disease is the commonest cause of death globally. The challenges that are facing the delivery of pediatric cardiac services will be discussed and some solutions will be suggested to improve these services. Pediatric cardiac services face huge economic, financial, social, and health care system delivery challenges. Collaboration between countries and non-governmental and philanthropy organizations is strongly needed to improve delivery of pediatric cardiac services in low-income and low-middle income countries. Planning of pediatric cardiac services in these countries should consider the context of each country or region; some countries managed to transform their pediatric cardiac services to be better.

Physicians’ Perceptions of and Satisfaction With Artificial Intelligence in Cancer Treatment: A Clinical Decision Support System Experience and Implications for Low-Middle–Income Countries

As technology continues to improve, health care systems have the opportunity to use a variety of innovative tools for decision-making, including artificial intelligence (AI) applications. However, there has been little research on the feasibility and efficacy of integrating AI systems into real-world clinical practice, especially from the perspectives of clinicians who use such tools. In this paper, we review physicians’ perceptions of and satisfaction with an AI tool, Watson for Oncology, which is used for the treatment of cancer. Watson for Oncology has been implemented in several different settings, including Brazil, China, India, South Korea, and Mexico. By focusing on the implementation of an AI-based clinical decision support system for oncology, we aim to demonstrate how AI can be both beneficial and challenging for cancer management globally and particularly for low-middle–income countries. By doing so, we hope to highlight the need for additional research on user experience and the unique social, cultural, and political barriers to the successful implementation of AI in low-middle–income countries for cancer care.

Culture Negative Sepsis after Pediatric Cardiac Surgery: Incidence and Outcomes

Background: A significant proportion of children after cardiac surgery with clinical features of blood stream sepsis do not have a positive blood culture and are managed as presumed ‘culture negative sepsis (CNS)’. There is little information on outcomes of CNS early after pediatric cardiac surgery. We sought to describe the incidence, outcomes and antibiotic utilization pattern of culture negative sepsis in children undergoing cardiac surgery.

Methods : 437 consecutive children who underwent cardiac surgery were studied. CNS was empirically defined as those in whom antibiotics were upgraded based on clinical and/or laboratory suspicion of blood stream sepsis with eventual negative blood culture. Outcomes were compared between three groups: normal controls, CNS and Culture Positive Sepsis (CPS).

Results: Incidence of CNS was 16% (71/437). The mortality was highest in CPS group (10.7%, 3/29); intermediate for CNS (2.9%, 2/71) and least for the normal group (1.2%, 4/337). Similarly, duration of ventilation and intensive care unit (ICU) length of stay (in hours) was highest for CPS (116 [45-271]; 288 [156-444]), intermediate for CNS (63 [23-112]; 192 [120-288]) and least for the normal group (18 [6-28]; 72 [48-120]). Third-tier antibiotics were initiated for 27 (40%) with CNS and 23 (92%) with CPS. Although the mean antibiotic duration for CNS (6.3±3.0 days) was less than CPS (9.09±5.12); p=0.022, 27.3% of CNS received antibiotics for more than one week.

Conclusion: The high incidence of CNS points towards the need for accurate biomarkers of bacterial sepsis after cardiac surgery. The relatively better outcomes of CNS merits consideration to rapidly de-escalate antibiotics for presumed sepsis after cardiac surgery.

Survival rate of pediatric osteosarcoma in Indonesia: a single center study

Background Over the years, the survival rate of children with osteosarcoma has increased with improved management. However, survival tends to be lower in low-middle-income countries.

Objective To report the survival rate of children with osteosarcoma in a single center in Indonesia and to evaluate the outcomes of treatment modalities currently used.

Methods We performed a retrospective analysis of the medical records of pediatric osteosarcoma patients in Cipto Mangunkusumo Hospital from 2015 to 2019. Patients were categorized based on age group, sex, primary tumor location, treatment modalities, disease metastasis, and disease outcome.

Results We included 83 children with osteosarcoma, with an age range of 4-17 years (median 13 years). Mean estimated overall survival and event-free survival were 28 (95%CI 24 to 32) months and 10 (95%CI 8 to 13) months, respectively. Overall survival duration between treatment modality groups was significantly different (P<0.05). The mean estimated overall duration of survival was 9 (95%CI 3 to 15) months for chemotherapy, 18 (95%CI 14 to 22) months for chemotherapy with surgery, and 21 (95%CI 14 to 27) months for chemotherapy with surgery and radiation.

Conclusion The survival rate of childhood osteosarcoma in Indonesia remains low. The current treatment option currently used in our center may contribute to the low rate of survival.

Quality improvement training for burn care in low-and middle-income countries: A pilot course for nurses

Background
There is an urgent need to empower practitioners to undertake quality improvement (QI) projects in burn services in low-middle income countries (LMICs). We piloted a course aimed to equip nurses working in these environments with the knowledge and skills to undertake such projects.

Methods
Eight nurses from five burns services across Malawi and Ethiopia took part in this pilot course, which was evaluated using a range of methods, including interviews and focus group discussions.

Results
Course evaluations reported that interactive activities were successful in supporting participants to devise QI projects. Appropriate online platforms were integral to creating a community of practice and maintaining engagement. Facilitators to a successful QI project were active individuals, supportive leadership, collaboration, effective knowledge sharing and demonstrable advantages of any proposed change. Barriers included: staff attitudes, poor leadership, negative culture towards training, resource limitations, staff rotation and poor access to information to guide practice.

Conclusions
The course demonstrated that by bringing nurses together, through interactive teaching and online forums, a supportive community of practice can be created. Future work will include investigating ways to scale up access to the course so staff can be supported to initiate and lead quality improvement in LMIC burn services.

Does in-hospital trauma mortality in urban Indian academic centres differ between “office-hours” and “after-hours”?

Introduction
Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity.

Method
Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into “Office-hours” and “After-hours”. Outcome parameters were compared between the above groups.

Results
5536 (68.4%) patients presented “after-hours” (AO) and 2561 (31.6%) during “office-hours” (OH). The in-hospital mortality for “after-hours” and “office-hours” presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9‐1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9–1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group.

Conclusion
The in-hospital mortality did not differ between trauma patients who arrived during “after-hours” compared to ‘“office-hours”.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

Background
Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

Methods
Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results
From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

Conclusions
Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center

Study Design:
Retrospective cost-effectiveness analysis.

Objectives:
While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.

Methods:
At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).

Results:
A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.

Conclusions:
This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.