Global variation of COVID-19 mortality rates in the initial phase

Objectives@#Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused devastation in over 200 countries. Italy, Spain, and the United States (US) were most severely affected by the first wave of the pandemic. The reasons why some countries were more strongly affected than others remain unknown. We identified the most-affected and lessaffected countries and states and explored environmental, host, and infrastructure risk factors that may explain differences in the SARS-CoV-2 mortality burden. @*Methods@#We identified the top 10 countries/US states with the highest deaths per population until May 2020. For each of these 10 case countries/states, we identified 6 control countries/ states with a similar population size and at least 3 times fewer deaths per population. We extracted data for 30 risk factors from publicly available, trusted sources. We compared case and control countries/states using the non-parametric Wilcoxon rank-sum test, and conducted a secondary cluster analysis to explore the relationship between the number of cases per population and the number of deaths per population using a scalable EM (expectation– maximization) clustering algorithm. @*Results@#Statistically significant differences were found in 16 of 30 investigated risk factors, the most important of which were temperature, neonatal and under-5 mortality rates, the percentage of under-5 deaths due to acute respiratory infections (ARIs) and diarrhea, and tuberculosis incidence (p < 0.05) @*Conclusion@#Countries with a higher burden of baseline pediatric mortality rates, higher pediatric mortality from preventable diseases like diarrhea and ARI, and higher tuberculosis incidence had lower rates of coronavirus disease 2019-associated mortality, supporting the hygiene hypothesis.

Global variation of COVID-19 mortality rates in the initial phase

Objectives@#Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused devastation in over 200 countries. Italy, Spain, and the United States (US) were most severely affected by the first wave of the pandemic. The reasons why some countries were more strongly affected than others remain unknown. We identified the most-affected and lessaffected countries and states and explored environmental, host, and infrastructure risk factors that may explain differences in the SARS-CoV-2 mortality burden. @*Methods@#We identified the top 10 countries/US states with the highest deaths per population until May 2020. For each of these 10 case countries/states, we identified 6 control countries/ states with a similar population size and at least 3 times fewer deaths per population. We extracted data for 30 risk factors from publicly available, trusted sources. We compared case and control countries/states using the non-parametric Wilcoxon rank-sum test, and conducted a secondary cluster analysis to explore the relationship between the number of cases per population and the number of deaths per population using a scalable EM (expectation– maximization) clustering algorithm. @*Results@#Statistically significant differences were found in 16 of 30 investigated risk factors, the most important of which were temperature, neonatal and under-5 mortality rates, the percentage of under-5 deaths due to acute respiratory infections (ARIs) and diarrhea, and tuberculosis incidence (p < 0.05) @*Conclusion@#Countries with a higher burden of baseline pediatric mortality rates, higher pediatric mortality from preventable diseases like diarrhea and ARI, and higher tuberculosis incidence had lower rates of coronavirus disease 2019-associated mortality, supporting the hygiene hypothesis.

Implementation of ventilator bundle in pediatric intensive care unit of a developing country

The aim of this study was to assess the frequency of VAP [ventilator associated pneumonia] after strict implementation of ventilator bundle in PICU. Medical records of all children [age 1 month - 16 years] were retrospectively reviewed, who were on mechanical ventilation [MV] for more than 48 hours and received all key components of "ventilator bundle" from January 2012 to December 2014. Out of 1050, 565 [54%] patients were enrolled. The mean age was 4.02 SD 4.29 years and 62 [69%] were male. The indications of MV were respiratory illness [54%], neurological illness [31%], shock [9%], and postoperative care [6%]. The mean duration of MV was 7.05 SD 5.4 days. Only 4 patients [0.7%] developed VAP. The incidence-density of VAP was 1.6 per 1000 ventilator days. The strict implementation of simple, inexpensive interventions [ventilator bundle] in care of mechanically ventilated children can decrease significantly VAP even in resource-limited country

Single incision laparoscopic cholecystectomy with conventional instruments and ports: initial experience at tertiary care public sector Hospital

Objective: To find out safety and feasibility of single incision laparoscopic cholecystectomy [SLIC] using conventional instruments

Methods: This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in order to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy

Results: Total no of cases were 50. The age ranged from 30-59 years [mean 35.20 years +/- 4.886.] There were 43[86%] females and 07[14%] males. The mean operating time was 80 minutes [range 50-120 +/- 16.020]. Four [8%] cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot's triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days [mean 1.08 +/- 0.274]

Conclusion: SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time

CVC related bacteremia; microbiologically confirmed, central venous catheter related bacteremia in intensive care unit pediatric patients

Objectives: To characterize clinically, epidemically and microbiologically the episodes of confirmed bacteremia associated with intravascular catheters of patients in the pediatric intensive care unit

Study Design: An analytical, prospective study

Setting: Intensive care unit of Pediatric Hospital José Luis Miranda"

Period: January 2003 to December 2007

Methods: 453 patients. Rates, density of incidence, risk factors, static's and mortality were determined and analyzed

Results: 96 patients developed bacteremia episodes and 90 [74%] had microbiological criteria. The risk factors associate were: to have multiple catheters, permanency with the catheter more than 7 days, parenteral feeding, prolonged mechanical ventilation, previous transfusions and surgical interventions. The isolations of coagulase negative staphylococci prevailed in 33 patients [36, 7%]. The previous demurrage to the insert of the catheter was of 4,0 +/- 9,4 days for the healthy ones and 11, 6 +/- 24,6 days in the sick persons [p = 0,000]; the definitive demurrage was of 56,1 +/- 62,4 days in the sick persons versus 24,6 +/- 31,7 days in the healthy ones [p = 0,000]. The mortality of the second group was superior [26%]

Conclusions: Multiple dependent and independent factors exist on which actions should be focused to prevent and to diminish the mortality by bacteremias associated with catheters in children admitted in intensive care units

Predictors of vaccination card retention in children 12-59 months old in Karachi, Pakistan

To determine the factors associated with retaining the vaccination card among care takers of 12-59 months old children in Karachi, Pakistan. This was an analytical cross-sectional study in Karachi. Households were randomly selected throughout a multistage cluster sampling technique. Data was collected for 504 children of 12- 59 months of age. Questionnaire was administered to caretakers to gather information regarding the children's vaccination status, socio-demographic characteristics and reviewing their vaccination cards. Statistical analysis was done by SPSS 19 using logistic regression. Among 462 vaccinated children, caretakers of 33% provided vaccination cards. Odds of card retention decrease if the caretaker has a large household i.e., >5 people sharing one room [AOR 0.277, 95% CI: 0.096, 0.797] and if the child is of four to five years of age [AOR 0.544, 95% CI: 0.305, 0.970]. Gender of the child, and the caretaker's education and access to electronic media were not significant predictors of vaccination card retention in our study. Our study showed that vaccination card retention for children 12-59 months of age was low [33%] in Karachi. There is a need to educate caretakers of young children regarding the importance of keeping vaccination card and to disseminate this information through healthcare providers. Improving vaccination card retention is one of the key measures which will help towards accurately estimating coverage and to inform health policy decisions

Experience of laparoscopic cholecystectomy during a steep learning curve at a university hospital

Cholelithiasis is the most common disease of alimentary tract affecting the adult population globally and our country in particular is no exception to it as a cause of hospitalization. Surgical removal of gall bladder is the main stay of symptomatic cholelithiasis ensuring a permanent cure. The minimally invasive technique of laparoscopic cholecystectomy has gained wide acceptance as a Gold Standard treatment ever since its introduction. The purpose of this prospective observational study was to document our experience of laparoscopic Cholecystectomy during a learning curve in a single unit of a university hospital and compare it with other available data in the literature. Total 94 patients underwent laparoscopic cholecystectomy during the learning curve from Jan 2009 to Dec 2010 in the Department of Surgery Liaquat University Hospital Jamshoro. Mean age was 42 years with females [88.29%] preponderance. Majority of the cases were operated by consultants [85.10%] within 25-60 minutes. Postoperative hospital stay was 3 days with return to work in 7 days. Only 6 [6.38%] cases were converted to open technique. Intra-peritoneal drains and Foley's catheter were kept in selected cases only. Eleven patients [11.70%] had intra-operative complications including complete transaction of CBD in only one [1.06%] male patient. Five patients [5.31%] had postoperative complications with two patients having iatrogenic duodenal injury which was not identified during surgery and pseudo cyst pancreas. Four patients [4.25%] died due to multiple organ failure. We conclude that Laparoscopic Cholecystectomy is a gold standard procedure and should be learned on virtual simulated models before starting this procedure on human patients.

Acute necrotizing encephalopathy of childhood: a fatal complication of swine flu

Acute necrotizing encephalopathy of childhood [ANEC] is a rare condition characterized by the presence of multifocal symmetrical brain lesions involving mainly thalami, brainstem, cerebellum and white matter. ANEC is a serious and life threatening complication of simple viral infections. We present a case of a young child who developed this condition with classical clinical and radiological findings consistent with ANEC, secondary to swine flu [H1N1]. He needed ventilatory support and had profound motor and intellectual deficit on discharge. We report this case with aim of raising awareness about this fatal complication of swine flu which has become a global health care issue these days

Outcome of the rubber band ligation with Milligan Morgan haemorrhoidectomy

Haemorrhoids is a common anorectal disease seen in our society. Conservative management is usually adopted for 1[st] and 2[nd] degree haemorrhoids. Patients who do not respond to above management are the candidates for other modalities of treatment which includes sclerotherapy, rubber band ligation, cryosurgery and stapler gun or open haemorrhoidectomy. The purpose of study was to compare the outcome of the Rubber band ligation with Milligan Morgan haemorrhoidectomy in patients with 2[nd] and 3[rd] degree haemorrhoids. Hundred diagnosed admitted patients of uncomplicated 2[nd] and 3[rd] degree piles were treated either with rubber band ligation [RBL] or open method of Milligan Morgan [OH] for the period from January 2007 to December 2007 were included in the study. Both procedures were evaluated regarding effectiveness, safety, complications after procedures, hospital stay and return to work on a written Performa. Patients with 1[st] and 4[th] degree haemorrhoids, below the age of 12 years, bleeding diathesis, associated local anorectal conditions requiring surgery, complicated haemorrhoids, recurrent and secondary haemorrhoids were excluded from the study. Follow up of all these patients was done in OPD to assess any complication and recurrence. Data was analysed through SPSS-16.0. One hundred indoor patients with 2[nd] and 3[rd] degree haemorrhoids were treated either with rubber band ligation or open technique. Most [>90%] of the patients were males. Majority of the patients were in 30-33 years age group. Fresh bleeding [90%] and constipation [45%] were the commonest symptoms followed by prolapsed, discharge and irritation. Second degree was more common than 3[rd] degree haemorrhoids. Intensive pain was the commonest complain after both the procedures, however faecal incontinence was not reported in either group. Hospital stay was longer in open technique [70%] compare to few hours to one day in rubber band ligation group. Return to work was earlier in patients treated with rubber band ligation. Rubber band ligation is safe and effective method compare to open technique in 2[nd] and 3[rd] degree symptomatic haemorrhoids

Prospective basic clinical audit using minimal clinical data set

Audit is a means of quality control for medical practice by which the profession should regulate its activities with intention of improving overall patient care. Objective of this study was to report 1 year basic clinical audit of a general surgical ward and comparison of results with available data. All patients admitted and managed in department of surgery unit-II, Liaquat University Hospital, Jamshoro/Hyderabad from January to December 2007 were included in the study for basic clinical audit. Data of all surgical patients admitted during this period were retrieved from the departmental register. Details of surgical procedures and complications were recorded from the patients' charts. Total number of patients was 1434, out of which 844 [58.85%] were males and 590 [41.14%] were females. Majority [70.02%] of the patients were between 16 to 50 years of age. Elective surgeries were performed in 487 [33.74%] and emergency surgeries in 430 [29.79%] cases, whereas rest of the 526 patients [36.28%] were managed conservatively. Consultant was the primary surgeon in less than 50% of the procedures compare to post graduate trainees and registrars. The most common surgeries performed in elective wing were inguinal hernia repairs [25.66%] and cholecystectomies [22.99%]. In emergency wing, most of the surgeries were exploratory laparotomies [38.13%] and appendicectomies [22.79%]. Average duration of hospital stay in elective wing was 1-10 days and in emergency wing it was 2-21 days. There was an overall complication rate of 6.3% and a mortality rate of 2.44% respectively. We conclude that surgical audit has potential benefits for patients, clinicians, and provision of services for a continuous education, research and improved practice habits and should be perform on yearly basis. We also recommend the proper computerised audit programs and committees for its monitoring and evaluation

Mucoepidermoid carcinoma of parotid presenting as unilocular cyst

An interesting case of a 09 years old girl is reported who presented with a painless, mobile, spherical, fluctuant and brilliantly translucent swelling in front of left ear. The fine needle aspiration revealed turbid dark yellow colour fluid. This cystic swelling was completely excised and the specimen on histopathology was reported as low grade Mucoepidermoid carcinoma. Recovery was uneventful. This unusual presentation of Mucoepidermoid carcinoma as a preauricular cyst is one of the rare unique reported case