Retrospective Analysis of Postoperative Nonhepatic Outcomes Following Major Liver Resection.

Background Liver surgery is a major and challenging procedure for the surgeon, the anesthetist, and the patient. The objective of this study was to evaluate the postoperative nonhepatic complications of patients undergoing liver resection surgery with perioperative factors. Methods We retrospectively analyzed 79 patients who underwent liver resection surgeries at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan, from July 2015 to December 2022. Results The mean age at the time of surgery was 53 years (range: 3-77 years), and the mean BMI was 26.43 (range: 15.72-38.0 kg/m2). Of the total patients, 44.3 % (n = 35) had no comorbidities, 26.6% (n=21) had one comorbidity, and 29.1% (n=23) had two or more comorbidities. Patients in whom the blood loss was more than 375 ml required postoperative oxygen inhalation with a significant relative risk of 2.6 (p=0.0392) and an odds ratio of 3.5 (p=0.0327). Similarly, patients who had a surgery time of more than five hours stayed in the hospital for more than seven days, with a statistically significant relative risk of 2.7 (p=0.0003) and odds ratio of 7.64 (p=0.0001). The duration of surgery was also linked with the possibility of requiring respiratory support, with a relative risk of 5.0 (p=0.0134) and odds ratio of 5.73 (p=0.1190). Conclusion Patients in our cohort who had a prolonged duration of surgery received an increased amount of fluids, and a large volume of blood loss was associated with prolonged stay in the ICU (>2 days), hospital admission (>7 days), ICU readmission, and increased incidence of cardiorespiratory, neurological, and renal disturbances postoperatively.

Orchestration and Management of Adaptive IoT-centric Distributed Applications.

Current Internet of Things (IoT) devices provide a diverse range of functionalities, ranging from measurement and dissemination of sensory data observation, to computation services for real-time data stream processing. In extreme situations such as emergencies, a significant benefit of IoT devices is that they can help gain a more complete situational understanding of the environment. However, this requires the ability to utilize IoT resources while taking into account location, battery life, and other constraints of the underlying edge and IoT devices. A dynamic approach is proposed for orchestration and management of distributed workflow applications using services available in cloud data centers, deployed on servers, or IoT devices at the network edge. Our proposed approach is specifically designed for knowledge-driven business process workflows that are adaptive, interactive, evolvable and emergent. A comprehensive empirical evaluation shows that the proposed approach is effective and resilient to situational changes.

Anesthetic Management of Emergency Insulinoma Resection: Case Report and Review of Literature.

Insulinoma, a neuroendocrine tumor originating from pancreatic islets, presents unique challenges in diagnosis and management. We present a case of a 73-year-old female with recurrent hypoglycemia leading to syncope, who underwent emergency pancreatectomy for a secreting insulinoma with multiple comorbidities. This case report aims to shed light on the complexities of insulinoma management and the importance of tailored perioperative strategies. The patient, presenting with severe hypoglycemia, was admitted for optimization. Preoperative assessment labeled her as ASA IVE and indicated a high risk of perioperative morbidity. General anesthesia, invasive monitoring, and epidural anesthesia were planned. Intraoperative glucose control was crucial, achieved with continuous blood glucose monitoring, octreotide administration, and insulin titration. The patient was extubated post-surgery, and pain was managed with epidural infusion. She was discharged on the 4th postoperative day with follow-up care. Insulinoma diagnosis relies on clinical, biochemical, and imaging tests, with 72-hour fasting as the gold standard. Localizing the tumor within the pancreas is essential for surgical success, often requiring invasive techniques. Surgical resection remains the definitive treatment, while medical management may be necessary in select cases. Anesthetic management should prioritize agents that minimize the cerebral metabolic rate for oxygen. Careful intraoperative glucose control and vigilant postoperative monitoring are essential. This case report highlights the intricate management of insulinoma, emphasizing tailored perioperative strategies that balance glucose regulation, anesthesia techniques, and postoperative care. However, the limited existing literature underscores the need for further research to refine anesthesia protocols, glucose control methods, and postoperative care, ultimately improving outcomes for patients with insulinoma.

Tonsillar Trauma During Video Laryngoscopy: A Case Report.

Potentially difficult airways warrant the use of airway adjuncts, which, if not used with caution, can cause trauma to the oral cavity. Although most operators are familiar with modern airway adjuncts, as they are not routinely used, adverse events can occur. Since its introduction, a video laryngoscope (VL) has been lauded as a necessary instrument for airway management in and out of the operating room. This case report highlights right tonsillar tissue perforation with a GlideScope® VL (Verathon Incorporated, Bothell, Washington, USA), requiring primary closure by an otolaryngologist.

Impact Of Incentive-Based Game Therapy And Transporting Children On Toy Vehicle To Operation Theatre On Reducing Anxiety Prior To Induction Of Anesthesia.

OBJECTIVE: To see if transporting paediatric patents to operation theatres using a battery operated vehicle decreases preoperative anxiety and reduce incidents of postoperative adverse events. METHODS: The study was conducted from May to August 2019 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised paediatric patients aged 3-5 years assessed as American Society of Anaesthesiologists grade I and II who were scheduled to undergo elective intrathecal chemotherapy under general anaesthesia. The subjects were randomised into intervention group A and control group B. Patients in group A were part of an incentive-based game in the holding bay area and were transported to the operation theatre using a battery-operated toy vehicle. Those in group B watched a pre-decided cartoon on television screen in the holding bay and were transported further using wheel chair. Induction of anaesthesia was done in the presence of guardians in both the groups. Patient anxiety was assessed using the modified Yale Preoperative Anxiety Scale in holding bay area T0, prior to induction of anaesthesia T1, and postoperative anaesthesia-related recovery T2. Data was analysed using SPSS 22. RESULTS: Of the 36 patients, 18(50%) were in group A; 12(66.6%) boys and 6(33.3%) girls with mean age 4.01±0.48 years. The remaining 18(50%) subjects were in group B; 13(72.2%) boys and 5(27.8%) girls with mean age 3.96 years. The difference in anxiety between the groups at T0 was non-significant (p=0.73). At T1 and T2, the scores were significantly lower group A compared to group B (p<0.05). Group A patients had better bag mask ventilation compliance at induction and remarkably less incidence of hypoxia, bronchospasm, postoperative agitation and early discharge from PACU. CONCLUSIONS: Incentive-based game therapy decreased anxiety among paediatric patients preoperatively, made them more compliant and improved postoperative recovery.

An Integrated Framework for Fault Resolution in Business Processes.

Cloud and edge-computing based platforms have enabled rapid development of distributed business process (BP) applications in a plug and play manner. However, these platforms do not provide the needed capabilities for identifying or repairing faults in BPs. Faults in BP may occur due to errors made by BP designers because of their lack of understanding of the underlying component services, misconfiguration of these services, or incorrect/incomplete BP workflow specifications. Such faults may not be discovered at design or development stage and may occur at runtime. In this paper, we present a unified framework for automated fault resolution in BPs. The proposed framework employs a novel and efficient fault resolution approach that extends the generate-and-validate program repair approach. In addition, we propose a hybrid approach that performs fault resolution by analyzing a faulty BP in isolation as well as by comparing with other BPs using similar services. This hybrid approach results in improved accuracy and broader coverage of fault types. We also perform an extensive experimental evaluation to compare the effectiveness of the proposed approach using a dataset of 208 faulty BPs.

A Framework for Dynamic Composition and Management of Emergency Response Processes.

An emergency response process outlines the workflow of different activities that need to be performed in response to an emergency. Effective emergency response requires communication and coordination with the operational systems belonging to different collaborating organizations. Therefore, it is necessary to establish information sharing and system-level interoperability among the diverse operational systems. Unlike typical e-government processes that are well structured and have a well-defined outcome, emergency response processes are knowledge-centric and their workflow structure and execution may evolve as the incident unfolds. It is impractical to define static plans and response process workflows for every possible situation. Instead, a dynamic response should be adaptable to the changing situation. We present an integrated approach that facilitates the dynamic composition of an executable response process. The proposed approach employs ontology-based reasoning to determine the default actions and resource requirements for the given incident and to identify relevant response organizations based on their jurisdictional and mutual aid agreement rules. The Web service APIs of the identified response organizations are then used to generate an executable response process that evolves dynamically. The proposed approach is implemented and experimentally validated using an example scenario derived from the FEMA Hazardous Materials Tabletop Exercises Manual.

Emergency Management of Ventilation Failure Through Blocked Tracheostomy Tube in a Paediatric Patient.

The most common complication of tracheostomy tubes in children is blockage of the tube. We report a case where ventilation after induction of anaesthesia was not possible even though there were no signs of impending obstruction. An eight-year-old child, recently diagnosed with left tonsillar embryonal rhabdomyosarcoma, presented for an MRI face and bone marrow biopsy before starting treatment. Due to difficulty in breathing, the patient had undergone a tracheostomy at a different institute and a size six uncuffed tracheostomy tube was in situ. There was difficulty in ventilating the patient due to blockage in the tracheostomy tube which was addressed and the patient was discharged after successful completion of both the procedures. This case highlights the importance of following an emergency algorithm for failure to ventilate in a patient with a tracheostomy tube, identifying the cause and treating it.

Clinical Practice for Venous Thromboembolism Prophylaxis in Patients Undergoing Oncological Surgeries.

Objective To determine the proportion of patients receiving venous thromboembolism (VTE) prophylaxis after oncological surgeries as per the hospital standards and its comparison with the international guidelines. Methodology In the month of September 2019, all patients after elective oncological surgeries were reviewed for VTE prophylaxis administration and education. Results were shared with the department of surgery and Hospital Quality and Patient Safety Department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis was revised followed by a loop audit which was done in October 2020. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines. Results Total 425 patients were included in this audit (209 in September 2019 and 216 in October 2020). Compliance with mechanical prophylaxis increased from 84.7 % to 98.6% and pharmacological prophylaxis improved from 39.7% (n=83) to 73.1% (n=158). Adherence to local protocols enhanced significantly from 1.9% (n=4) to 56.4% (n=122). The main cause of non-compliance was lack of risk assessment for VTE. Conclusion VTE prophylaxis can be improved by setting protocols in accordance with the international guidelines and local protocols. This can prevent significant morbidity and mortality in surgical patients as well as hospital costs.

SARS-CoV-2 UK, South African and Brazilian Variants in Karachi- Pakistan

COVID-19 pandemic has been evolving in Pakistan since the UK, South African and Brazilian variants have started surfacing which are known for increase transmissibility and can also be responsible for escape from immune responses. The gold standard to detect these variants of concern is sequencing, however routine genomic surveillance in resource limited countries like Pakistan is not always readily available. With the emergence of variants of concern and a dearth of facilities for genomic scrutiny leaves policy makers and health authorities an inconsistent and twisted image to make decisions. The inadvertent detection of B.1.1.7 by target failure because of a key deletion in spike {Delta}69-70 in the UK by commercially available COVID-19 PCR assay helps to understand target failures as an alternative approach to detect variants. It was ascertained further that a deletion in the ORF1a gene (ORF1a {Delta}3675-3677) found common in B.1.1.7, B.135 and P.1 variants of concern. The Real Time Quantitative PCR (RT-qPCR) assay for detection of emergence and spread of SARS-CoV-2 variants, by these target failures is used here. The positive samples archived in respective labs were divided in two groups used in the present study. Group I constitutes 261 positive samples out of 16964 (1.53%) collected from August till September 2020. Group II include 3501 positive samples out of 46041 (7.60%) from November 2020 till January 2021. In positive samples of group I, no variant of concern was found. A staggering difference in results was noted in group II where positivity ratio increased exponentially and the variants of concern started appearing in significant numbers (53.64% overall). This is indicative that the third wave in Pakistan is due to the importation of SARS-CoV-2 variants. This calls for measures to increase surveillance by RT-qPCR which would help authorities in decision making.

A Service-oriented Framework for Developing Personalized Patient Care Plans for COVID-19.

The COVID-19 pandemic has identified weaknesses and stresses in the existing healthcare and governance system, even in the most developed countries. Given the scale and scope of the pandemic, existing healthcare systems are heavily resource constrained, and home-based isolation has been considered as a potential first step for reducing both the disease spread and the stress on the healthcare system. However, the needs and requirements of home-based isolation are extremely unique for each patient, depending on their medical condition and comorbidities, family responsibilities, and environmental constraints. Therefore, it is necessary to develop personalized patient care plans to ensure that the needs of each patient are appropriately met. In this paper we propose a service oriented framework that allows dynamic composition and management of such plans assuming existence of an appropriate knowledge base and availability of web-services interfaces of the underlying systems of caregivers and service providers. We develop a prototype implementation to show the feasibility of the proposed framework and discuss the challenges/issues in deploying such a system in practice.

Blockchain Based Auditable Access Control for Distributed Business Processes.

The use of blockchain technology has been proposed to provide auditable access control for individual resources. However, when all resources are owned by a single organization, such expensive solutions may not be needed. In this work we focus on distributed applications such as business processes and distributed workflows. These applications are often composed of multiple resources/services that are subject to the security and access control policies of different organizational domains. Here, blockchains can provide an attractive decentralized solution to provide auditability. However, the underlying access control policies may be overlapping in terms of the component conditions/rules, and simply using existing solutions would result in repeated evaluation of user's authorization separately for each resource, leading to significant overhead in terms of cost and computation time over the blockchain. To address this challenge, we propose an approach that formulates a constraint optimization problem to generate an optimal composite access control policy. This policy is in compliance with all the local access control policies and minimizes the policy evaluation cost over the blockchain. The developed smart contract(s) can then be deployed to the blockchain, and used for access control enforcement. We also discuss how the access control enforcement can be audited using a game-theoretic approach to minimize cost. We have implemented the initial prototype of our approach using Ethereum as the underlying blockchain and experimentally validated the effectiveness and efficiency of our approach.