The role and response of primary healthcare services in the delivery of palliative care in epidemics and pandemics : a rapid review to inform practice and service delivery during the COVID-19 pandemic

Background: The increased number of deaths in the community happening as a result of COVID-19 has caused primary healthcare services to change their traditional service delivery in a short timeframe. Services are quickly adapting to new challenges in the practical delivery of end-of-life care to patients in the community including through virtual consultations and in the provision of timely symptom control. Aim: To synthesise existing evidence related to the delivery of palliative and end-of-life care by primary healthcare professionals in epidemics and pandemics. Design: Rapid systematic review using modified systematic review methods, with narrative synthesis of the evidence. Data sources: Searches were carried out in Medline, Embase, PsychINFO, CINAHL and Web of Science on 7th March 2020. Results: Only five studies met the inclusion criteria, highlighting a striking lack of evidence base for the response of primary healthcare services in palliative care during epidemics and pandemics. All were observational studies. Findings were synthesised using a pandemic response framework according to ‘systems’ (community providers feeling disadvantaged in terms of receiving timely information and protocols), ‘space’ (recognised need for more care in the community), ‘staff’ (training needs and resilience) and ‘stuff’ (other aspects of managing care in pandemics including personal protective equipment, cleaning care settings and access to investigations). Conclusions: As the COVID-19 pandemic progresses, there is an urgent need for research to provide increased understanding of the role of primary care and community nursing services in palliative care, alongside hospices and community specialist palliative care providers

Consensus guidelines for the management of adult high-grade gliomas for lowand middle-income countries

High-grade glioma (HGG), a formidable and often incurable disease, presents an even greater challenge in low- and middle-income countries (LMICs) where resources and medical expertise are scarce. This scarcity not only exacerbates the suffering of patients but also contributes to poorer clinical outcomes. Particularly in LMICs, the underrepresentation of the population in clinical trials and the additional hurdles posed by financial constraints underscore an urgent need for contextspecific management strategies. In response, we have rigorously evaluated recent guidelines from leading medical societies, adapting them to suit the specific needs and limitations of the local context in Pakistan. This effort, undertaken in collaboration with local physicians, aims to provide a comprehensive, standardised approach to diagnose, treat, and follow-up with HGG patients. By focussing on the best available clinical evidence and judicious use of limited resources, we strive to improve patient care and outcomes in these challenging settings. Keywords: Patient care, societies, medical, physicians, glioma, brain tumour

Judicious and evidence-based use of radiosurgery - recommendations for low- middle income countries

Surgical removal remains the primary treatment for most brain tumours. However, radiosurgery presents an effective, less invasive alternative or additional treatment for certain types. Our goal was to explore radiosurgery's roles in treating various brain tumours, focussing on its application in low- and middle-income countries (LMICs). We reviewed all relevant systematic reviews, metaanalyses, and guidelines to determine the most effective radiosurgical approaches. Additionally, we consulted a panel of experts with over ten years of experience in LMICs, such as Pakistan. For brain tumours, stereotactic radiosurgery should generally follow a confirmed histopathological diagnosis. Exceptions include tumours identified through Magnetic Resonance Imaging (MRI), like Vestibular Schwannoma (VS), pre-diagnosed Neurofibromatosis type 2 (NF2), multiple typical meningiomas, and metastases with a known histology from another site. While radiosurgery is gaining traction as a primary and adjunct treatment in some LMICs, the lack of regional guidelines, trained personnel, and collaboration among specialists hinders its wider adoption. Addressing these gaps is crucial for expanding radiosurgical care in these regions. Keywords: Meningeal neoplasms, neurofibromatosis, neuroma, acoustic, meningioma, Radiosurgery, brain neoplasms, magnetic resonance imaging, pituitary tumour, glioma, vestibular schwannoma

Consensus guidelines for the management of adult low-grade gliomas for low and middle-income countries

Low-grade gliomas (LGG) are brain tumors of glial cells origin. They are grade 1 and grade 2 tumors according to the WHO classification. Diagnosis of LGG is made through imaging, histopathological analysis, and use of molecular markers. Imaging alone does not establish the grade of the tumor and thus a histopathological examination of tissue is crucial in establishing the definite histopathological diagnosis. Clinical presentation varies according to the location and size of the tumor. Surgical resection is strongly recommended in LGG over observation to improve overall survival as surgery leads to greater benefit due to progression-free survival. Radiation has shown benefits in LGG patients in randomized controlled trials and chemotherapy with temozolomide has also shown good results. This paper covers the principles of low-grade gliomas management and summarizes the recommendations for the LMICs. Keywords: Temozolomide, survival, brain Neoplasms, glioma, neurogli

Consensus guidelines for the management of primary central nervous system lymphoma for low and middle-income countries

Primary lymphoma of the central nervous system (PCNSL) is a rare and aggressive form of extranodal non-Hodgkin lymphoma primarily involving the brain, spinal cord, cerebrospinal fluid, and eyes. The role of surgical intervention in PCNSL is currently limited to biopsy and decompression of critical structures if needed – extended resection is debated. Chemotherapy is the mainstay of treatment. In lower and middle-income countries (LMICs), issues like delayed diagnosis and resource constraints are widespread. These guidelines provide a framework for addressing PCNSL in LMICs, emphasizing the importance of early diagnosis, tailored treatment approaches, and ongoing patient monitoring to improve outcomes for this rare and aggressive disease. Keywords: Lymphoma, non-Hodgkin, biopsy, nervous system, physiologic decompression, spinal cord, brain tumour

Consensus guidelines for the management of intracranial meningioma for lowand middle-income countries

Intra-cranial meningiomas represent the most common type of extra-axial brain tumour in adults. Characteristically slow-growing and often asymptomatic, these tumours may only require observation in some cases. However, lesions that cause a significant mass effect necessitate intervention, primarily through surgical means. Additionally, in cases of significant unresectable low-grade residual meningioma or high-grade tumours, radiation therapy becomes essential. Notably, current management guidelines predominantly reflect data derived from high-income countries, failing to address constraints prevalent in the developing world, such as limited financial resources and restricted access to advanced surgical facilities. This manuscript introduces guidelines specifically tailored for the management of meningioma in patients from low- and middle-income countries, considering their unique healthcare challenges and resources. Keywords: Meningioma, brain neoplasms, health care, neurooncology

Consensus guidelines for the management of intracranial ependymoma for low- and middle-income countries

This paper presents comprehensive consensus guidelinesfor the management of intracranial ependymoma,neoplasms arising from ependymal cells in the centralnervous system's ventricular system, in low- and middleincomecountries (LMICs). Acknowledging the distinctepidemiological patterns of ependymomas, notably theirhigher incidence in paediatric patients, and variablesurvival rates, these guidelines emphasize tailoredmanagement approaches for different age groups. Anexpert panel, comprising specialists in neuro-oncology,convened to address gaps in diagnosis and managementwithin LMICs, considering the varying clinicalpresentation based on tumour size and location.Emphasizing surgical intervention as the cornerstone oftreatment, the guidelines also address challenges such asintraoperative bleeding and tumour location impactingcomplete resection. The role of molecular subgrouping instratifying treatment and predicting prognosis ishighlighted, alongside a careful consideration ofradiotherapy timing, dose, and volume based on riskfactors. Chemotherapy's role, especially in paediatriccases, is explored. The paper synthesizes current researchand expert opinions, including the need forstandardisation, genetic testing, and exploration of lessinvasive treatment modalities, to address the uniquehealthcare infrastructure challenges in LMICs. Theguidelines also emphasize multidisciplinary teams,aiming to bridge the care gap between high-incomecountries and LMICs, and improve survival rates andquality of life for patients with intracranial ependymoma.This article serves as a valuable resource for clinicians,researchers, and policymakers in Pakistan and beyond,facilitating the development of evidence-based strategiesin diverse healthcare settings. Keywords: Nervous system, genetic, ependymoma,prognosis, ependymoma, surgery, radiotherapy

Consensus guidelines for the management of intracranial metastases for low- and middle-income countries

Metastatic tumours are among the most common types of brain tumours. However, in low- and middle-income countries (LMICs), the numbers are considerably lower. This does not necessarily indicate a decreased incidence but rather points to decreased survival rates or limited access to healthcare. The challenge of achieving better outcomes, along with associated costs and resource constraints, often hinders the effective management of brain metastasis. Even in cases where localised disease can potentially be managed to improve survival, these challenges persist. The purpose of these guidelines is to address these challenges and outline a management strategy within the context of LMICs. Keywords:Incidence, survival rate, health care, brain neoplasms, metastases, tumour

Consensus guidelines for the management of pineal region tumours for low- and middle-income countries

Pineal region tumours are rare and mainly arise at ayounger age. They can be categorized into various types:germ cell tumours (GCT), pineal parenchymal tumours(PPT), meningiomas, gliomas, pineoblastoma, pinealparenchymal tumours of intermediate differentiation,papillary tumours of the pineal region, and SMARCB1-mutant desmoplastic myxoid tumour. Within GCT,germinomas are the most prevalent, comprising themajority of tumours in this region, while nongerminomatousGCTs are also present. In rare instances,metastases from other sites may manifest. These tumoursoften lead to obstructive hydrocephalus and commonlyexhibit symptoms related to mass effect, includingheadache, nausea, vomiting, and impaired gait stability.Different subtypes of pineal region tumours exhibitdistinct radiological characteristics, thus imaging remainsthe primary diagnostic tool. Histologic diagnosisnecessitates biopsy, unless in cases of germ cell tumours,particularly germinomas, which can be identified throughelevated levels of tumour markers like alpha-fetoprotein(AFP) and human chorionic gonadotropin (HCG) in bothcerebrospinal fluid (CSF) and serum. While benigntumours might be effectively treated with radicalresection alone, malignant tumours demand additionalchemotherapy and radiotherapy following surgicalremoval. Keywords: Pinealoma, alpha-fetoproteins,meningioma, germinoma, chorionic, gonadotropin,hydrocephalus, headache, vomiting, glioma, biopsy,nausea, gait, tumours