Exploring the implications of the first COVID-19 lockdown on patients with melanoma: a national survey.

The impact of the COVID-19 pandemic upon care of malignant melanoma (MM) remains as yet poorly understood. We undertook a UK-wide national survey, in conjunction with a patient support group (Melanoma UK), to explore patient perceptions of the impact of the pandemic upon treatment and outpatient care of their MM. Our findings suggest that following the onset of COVID-19, a significant minority of treatments and appointments have been delayed, there has been a shift from face-to-face to virtual outpatient consultations and there may be a rise in psychological comorbidities in patients with MM. We would urge clinicians to consider mental health interventions as part of a holistic care package.

Predicting outcomes after acute reperfusion therapy for basilar artery occlusion.

BACKGROUND AND PURPOSE: Basilar artery occlusion (BAO) leads to high rates of morbidity and mortality, despite successful recanalization. The discordance between flow restoration and long-term functional status clouds clinical decision-making regarding further aggressive care. We sought to develop and validate a practical, prognostic tool for the prediction of 3-month favorable outcome after acute reperfusion therapy for BAO. METHODS: This retrospective, multicenter, observational study was conducted at four high-volume stroke centers in the USA and Europe. Multivariate regression analysis was performed to identify predictors of favorable outcome (90-day modified Rankin scale scores 0-2) and derive a clinically applicable prognostic model (the Pittsburgh Outcomes after Stroke Thrombectomy-Vertebrobasilar (POST-VB) score). The POST-VB score was evaluated and internally validated with regard to calibration and discriminatory ability. External validity was assessed in patient cohorts at three separate centers. RESULTS: In the derivation cohort of 59 patients, independent predictors of favorable outcome included smaller brainstem infarct volume on post-procedure magnetic resonance imaging (P < 0.01) and younger age (P = 0.01). POST-VB score was calculated as: age + (10 × brainstem infarct volume). POST-VB score demonstrated excellent discriminatory ability [area under the receiver-operating characteristic curve (AUC) = 0.91] and adequate calibration (P = 0.88) in the derivation cohort (Center A). It performed equally well across the three external validation cohorts (Center B, AUC = 0.89; Center C, AUC = 0.78; Center D, AUC = 0.80). Overall, a POST-VB score < 49 was associated with an 88% likelihood of favorable outcome, as compared to 4% with a score ≥ 125. CONCLUSIONS: The POST-VB score effectively predicts 3-month functional outcome following acute reperfusion therapy for BAO and may aid in guiding post-procedural care.

Draft genome of a macrolide resistant XDR Salmonella enterica serovar Paratyphi A strain using a shotgun sequencing approach.

OBJECTIVES: Salmonella enterica serovar Paratyphi A, the causative pathogen of enteric fever, is a major public-health concern affecting millions of people around the world. We conducted whole-genome sequencing and analysis of a novel macrolide-resistant Salmonella Paratyphi A strain isolated from Karachi, Pakistan. METHODS: Genomic DNA of Salmonella Paratyphi A strain JRCGR-AK14 was sequenced on a MiSeq platform. Read quality was evaluated and paired-end reads were assembled into contigs and scaffolds. The quality of contigs and scaffolds was evaluated and assembled contigs were annotated. Virulence genes, antimicrobial resistance genes (ARGs), tRNAs, rRNAs, coding sequences and clustered regularly interspaced short palindromic repeats (CRISPRs) were identified. ARGs and mutations in quinolone-resistance determining regions (QRDRs) were identified by Antimicrobial Resistance Identification By Assembly (ARIBA) and ResFinder. Known and unknow mutations in the QRDRs were predicted. RESULTS: The genome of Salmonella Paratyphi A was calculated at 4529866 bp with 4381 genes and 1088 hypothetical proteins. Several putative genes coding for multidrug efflux pumps were identified. In addition, gene mutations conferring resistance to nitrofurantoin (e.g. marA, mdsC, Escherichia coli soxS), pulvomycin (e.g. H-NS, cpxA, E. coli EF-Tu) and fosfomycin (CRP, kdpE, E. coli glpT) were also identified. Several ARGs along with the mobile genetic element transposon Tn10 were also identified. It is evident from the results that diverse redundant mechanisms are involved in regulation of drug resistance in this strain. CONCLUSION: The current findings provide valuable data for understanding the multidrug resistance and pathogenic characteristics of clinical Salmonella Paratyphi A isolates.

Malignant neoplasms of Meckel's diverticulum; an evidence based review.

An up to date published literature has shown that Meckel's Diverticulum (MD) are discovered incidentally and are benign, malignant transformation is unusual with reported incidence to be only 0.5%-3.2%. The research available on this rare tumour remains scanty, mainly consisting of case reports and case series with many researchers reporting on their own clinical experience and often disagree on not only its epidemiology, but also more so on its surgical indications. In addition to the above there is no agreed standard formal grading and staging classification for primary MD tumour that can not only help assess the tumour in a systematic way, but also advise on a standard treatment plan that is to be followed after emergency surgery. Hence, the aim of this article is to systematically review the latest evidence on these rare types of malignant neoplasm originating from MD, and conclude the best management options when encountered with such situations.

Effect on neonatal outcome of pharmacological interventions for attenuation of the maternal haemodynamic response to tracheal intubation: a systematic review.

The primary aim of this systematic review was to assess the effect on neonatal outcome of pharmacological interventions used for attenuation of the haemodynamic response to tracheal intubation in patients undergoing caesarean section under general anaesthesia. A systematic search of randomised controlled trials from 1990 to 2015 was conducted. The primary outcome measure was the Apgar score at five minutes and secondary outcomes were umbilical arterial blood gas parameters and neurological adaptive capacity scores. Twenty-seven randomised controlled trials (1,689 patients) were included in the qualitative synthesis. Only five studies using opioids (383 patients) and five studies using non-opioid analgesics (358 patients) were subjected to meta-analysis. The Apgar score at five minutes was significantly lower in neonates of opioid-treated mothers (mean difference: -0.29, 95% confidence interval -0.56 to -0.02, P-value=0.03) compared to mothers in the control group; the umbilical arterial pH was lower and there was a higher requirement for tactile stimulation in neonates. No difference was seen in Apgar scores of neonates of mothers administered non-opioid analgesics compared to placebo. No difference was observed in other parameters between opioid- or non-opioid-treated mothers. This review suggests that opioid interventions for attenuation of the haemodynamic response to tracheal intubation in pregnant patients under general anaesthesia affect neonatal Apgar scores at five minutes in neonates but the difference did not appear to be clinically meaningful. We were unable to demonstrate any difference in safety.

Outcome of aortoiliac, femoropopliteal and infrapopliteal endovascular interventions in lesions categorised by TASC classification.

AIM: To analyse lower limb angioplasty results using the defined anatomical classification of the Trans-Atlantic Inter-Society Consensus (TASC) in a training environment and to compare the results with published data. MATERIALS AND METHODS: Retrospective, consecutive data were collected for a period of 1 year for all patients undergoing lower limb endovascular interventions. The radiology information system and notes were used to obtain clinical data, and angiograms were reviewed in all cases. All cases were performed or supervised by five vascular interventional consultants assisted by fellows or registrars. Patient demographics, the indication for treatment, the TASC classification of the treated lesion, calcification, use of stent, technical success (residual stenosis <20% on completion angiography), and complications were assessed. RESULTS: Two hundred and sixty-two lesions were treated. Of the aortoiliac lesions (83), the overall primary technical success rate was 91.6% (TASC A and B: 96.7%, TASC C and D: 77.3%). Sixty-one lesions were stented and no complications recorded. Of the femoropopliteal lesions (n = 123), the overall primary technical success rate was 91.9% (TASC A and B: 98.7%, TASC C and D: 80.9%). There were four major and five minor complications in this group (five groin haematomas, two vessel ruptures, one retroperitoneal haematoma, and one distal embolization). Five patients were stented. In the infrapopliteal group (n = 56), the overall primary technical success rate was 91.1% (TASC A and B: 96.3%, TASC C and D: 86.2%). There was one complication (small retroperitoneal hematoma) and two stents were used. CONCLUSION: The results of the present study showed good technical success and low complication rates in lower limb endovascular interventions with variable operator expertise. The results are comparable to published data. Use of the TASC classification system is encouraged as it allows an objective assessment of severity and enables standardized comparison.

Early postoperative outcome after curative colorectal cancer surgery.

INTRODUCTION: Colorectal cancer is uncommon in the Indian subcontinent, so there is a paucity of outcome data from this region. The aim of our study was to identify risk factors for early postoperative morbidity and mortality following curative colorectal cancer surgery in our set-up. METHODS: The data on patients with pathologically confirmed colorectal cancer who underwent curative surgery at Aga Khan University Hospital, Karachi, Pakistan, between January 1999 and December 2008 were recorded. Patients who developed early postoperative morbidity or mortality were compared with those who followed a healthy course after surgery. RESULTS: A total of 250 consecutive patients underwent colorectal cancer surgery during the study period. Postoperative complications were found in 34.8 percent of the patients, out of which four deaths occurred. Serum albumin level less than 3.5 g/dl (odds ratio [OR] 3.75, 95 percent confidence interval [CI] 1.37-10.23) and tumours involving the left colon (OR 2.60, 95 percent CI 1.02-6.64) were identified as independent risk factors for early postoperative complications on multivariate analysis. CONCLUSION: A low serum albumin level and the presence of a left-sided colonic tumour were significant risk factors for early postoperative complications. Information on these complications and the risk factors for early postoperative outcome is an important consideration for patients and surgeons.

Human papillomavirus infection in women with and without cervical cancer in Karachi, Pakistan.

BACKGROUND: No data exist on the population prevalence of, or risk factors for, human papillomavirus (HPV) infection in predominantly Muslim countries in Asia. METHODS: Cervical specimens were obtained from 899 married women aged 15-59 years from the general population of Karachi, Pakistan and from 91 locally diagnosed invasive cervical cancers (ICCs). HPV was detected using a GP5+/6+ PCR-based assay. RESULTS: The prevalence of HPV in the general population was 2.8%, with no evidence of higher HPV prevalence in young women. The positivity of HPV was associated with women's lifetime number of sexual partners, but particularly with the age difference between spouses and other husbands' characteristics, such as extramarital sexual relationships and regular absence from home. The HPV16/18 accounted for 24 and 88% of HPV-positive women in the general population and ICC, respectively. CONCLUSION: Cervical cancer prevention policies should take into account the low HPV prevalence and low acceptability of gynaecological examination in this population.

Congenital lung lesions: classification and concordance of radiological appearance and surgical pathology.

Congenital lung lesions are diagnosed antenatally in the majority of cases. Postnatal management includes chest radiography and CT-scanning, followed by either surgical resection or CT surveillance. Pre-operatively, lesions are often "labelled" as CCAM (and the Stocker classification incorrectly applied), sequestration, or lobar emphysema, and their frequent "hybrid" nature sometimes missed. The aim of our study was to correlate antenatal and postnatal radiological diagnoses and classification of congenital lung lesions with surgical and pathological outcome. Twenty-six consecutive cases of antenatally-diagnosed cystic lung lesions managed at our centre between January 2003 and April 2007 were reviewed. Diagnoses were: cystic adenomatoid malformations (CCAM) in 13 cases (50.0%), three bronchopulmonary sequestrations (11.5%), "hybrid" lesions in eight cases (30.8%), one isolated lobar emphysema (3.8%) and a normal lung segment with anomalous systemic supply (3.8%). Overall concordance rate between prenatal ultrasound and resection pathology was 61.5%, whereas CT findings correlated with pathology in 65.4% of cases. Incorrect radiological classification resulted in one morbidity, when an attempted thoracoscopic resection of a presumed CCAM had to be converted to an open procedure due to bleeding from an unsuspected anomalous vessel. The common embryological origin of these lesions, and the need for standardisation of reporting is discussed. We propose that lesions should be classified anatomically according to their nature, arterial supply and venous drainage in order to reduce discrepancies between radiological, intra-operative and pathological reporting.

Worldwide variation in the relative importance of hepatitis B and hepatitis C viruses in hepatocellular carcinoma: a systematic review.

We combined information published worldwide on the seroprevalence of hepatitis B surface antigen (HbsAg) and antibodies against hepatitis C virus (anti-HCV) in 27 881 hepatocellular carcinomas (HCCs) from 90 studies. A predominance of HBsAg was found in HCCs from most Asian, African and Latin American countries, but anti-HCV predominated in Japan, Pakistan, Mongolia and Egypt. Anti-HCV was found more often than HBsAg in Europe and the United States.

The role of family configuration in early childhood intellectual development in the context of an extended family system in Pakistan.

CONTEXT: The confluence theory of intelligence by Zajonc and Markus emphasizes that individual intellectual difference of children manifests itself in the context of family configuration. Instead of assuming its generalizability, careful scientific work is required before applying the model to South Asian cultures where, predominantly, an extended family type exists. AIMS: To assess the role of extended family configuration on the child's intellectual development in a South Asian setting. SETTINGS AND DESIGN: A cross-sectional study was conducted on 4-5-year-old preschool children residing in Karachi, Pakistan. MATERIALS AND METHODS: Three hundred and forty-two child and mother dyads were assessed through a validated cognitive psychometric tool and through a structured questionnaire. Children who were registered at the main Mother and Child Health Centres (MCH) of the Aga Khan Health Services, Pakistan (AKHSP) Karachi and who were born between July 1st 1993-June 30th 1994 with traceable birth records at the maternity homes, were considered for this study. STATISTICAL ANALYSIS: Multivariate linear regression models were used to identify the individual effect of family configuration on the intellectual scores. RESULTS: Family configuration variables such as number of co-residents ( P P CONCLUSION: The findings suggest the positive role of co-residents of an extended family environment on the intellectual development in early childhood.

Residents' perceptions of work environment during their postgraduate medical training in Pakistan.

BACKGROUND: In Pakistan, there is a lack of information about the work environment of residency programs. This lack is a major impediment in their improvement. One of the approaches for improvement in these programs can be directed through the residents' own perception of their working conditions. Therefore, we collected data which would reflect working conditions of residents. AIM: To assess the perceived status of "work environment" in different specialities. MATERIALS AND METHODS: A cross-sectional survey was conducted in four teaching hospitals of Karachi from July 1999 to January 2000. Residents from selected programs were grouped into four broad groups: specialist, medical, surgical and multidisciplinary. Responses of residents were obtained on a Likert scale of 0 to 4. Indices were formed for two components of work environment: academic and mistreatment. STATISTICAL ANALYSIS: Differences between residents' groups were assessed through analysis of variance (ANOVA) at 5% significance. RESULTS: A total of 341 registered residents responded (response rate: 75%). Surgical residents were working more than 80 h/week and this was more than the other three groups. Medical residents were spending the highest actual time on research and teaching activities (10% and 14%, respectively). Academic index score was highest for surgical group (15.81, SD = 4.69) and lowest for multidisciplinary group (11.82, SD = 4.80). Medical group had the highest perceived mistreatment index score (5.56, SD = 4.57). CONCLUSIONS: In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions. Most of the residents recognized undergraduate teaching, grand rounds, patient rounds and seminars or workshops as contributing to their academic learning. Reporting of sexual harassment was low, indicating either underreporting or cultural dynamics of our setting.

Residents' perceptions of communication skills in postgraduate medical training programs of Pakistan.

BACKGROUND: The importance of communication skills in postgraduate medical training is likely to be highlighted given the convergence of research and educational forces. Assessment of these skills in residency training is vital since it can provide basis for policy undertaking among Pakistani medical academia for improving postgraduate training programs. AIM: To assess the perceived status of communication skills of residents in different specialties. MATERIALS AND METHODS: A cross sectional survey was conducted in four teaching hospitals of Karachi between July 1999 and January 2001. A total of 455 residents in different residency programs were contacted. Residents registered both with College of Physicians and Surgeons of Pakistan and Postgraduate Medical Education office of selected hospitals were included in this study. Responses of residents were obtained on 5-point Likert scale. Indices were formed for three components of communication skills: informative, affective and professional communication. STATISTICAL ANALYSIS: Differences between residents' groups were assessed through analysis of variance. RESULTS: Total informative communication index was lowest for multi-disciplinary (12.05, SD = 4.87) and highest for surgical (15.27, SD = 2.51) residents. Total affective index was lowest for multi-disciplinary (12.58, SD = 5.68) and highest for medical (15.74, SD = 3.59) residents. The group differences for four groups of residency programs were not statistically significant for either professional attributes separately or for the total professional index. CONCLUSIONS: The residency programs must establish goals, process and outcomes to incorporate communication skills in postgraduate medical training since this can enhance residents' performance as effective health care providers. Accomplishment of better communication skills can be achieved if the importance of its teaching and training is valued by residency program coordinators.

Conversion from laparoscopic to open cholecystectomy: multivariate analysis of preoperative risk factors.

BACKGROUND: Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic cholelithiasis. Some patients require conversion to open surgery and several preoperative variables have been identified as risk factors that are helpful in predicting the probability of conversion. However, there is a need to devise a risk-scoring system based on the identified risk factors to (a) predict the risk of conversion preoperatively for selected patients, (b) prepare the patient psychologically, (c) arrange operating schedules accordingly, and (d) minimize the procedure-related cost and help overcome financial constraints, which is a significant problem in developing countries. AIM: This study was aimed to evaluate preoperative risk factors for conversion from laparoscopic to open cholecystectomy in our setting. SETTINGS AND DESIGNS: A case control study of patients who underwent laparoscopic surgery from January 1997 to December 2001 was conducted at the Aga Khan University Hospital, Karachi, Pakistan. MATERIALS AND METHODS: All those patients who were converted to open surgery (n = 73) were enrolled as cases. Two controls who had successful laparoscopic surgery (n = 146) were matched with each case for operating surgeon and closest date of surgery. STATISTICAL ANALYSIS USED: Descriptive statistics were computed and, univariate and multivariate analysis was done through multiple logistic regression. RESULTS: The final multivariate model identified two risk factors for conversion: ultrasonographic signs of inflammation (adjusted odds ratio [aOR] = 8.5; 95% confidence interval [CI]: 3.3, 21.9) and age > 60 years (aOR = 8.1; 95% CI: 2.9, 22.2) after adjusting for physical signs, alkaline phosphatase and BMI levels. CONCLUSION: Preoperative risk factors evaluated by the present study confirm the likelihood of conversion. Recognition of these factors is important for understanding the characteristics of patients at a higher risk of conversion.

A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan.

BACKGROUND: Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting. AIM: The study was carried out to identify risk factors for NNT in Karachi. MATERIALS AND METHODS: Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case. STATISTICAL ANALYSIS: Conditional logistic regression was performed to assess the independent effect of factors associated with NNT. RESULTS: The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%. CONCLUSION: Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.

Factors influencing the selection of surgical specialty among Pakistani medical graduates.

CONTEXT: The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates' careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection. AIMS: To identify the different factors that influence the graduates to select surgical specialties in Pakistan. SETTINGS AND DESIGNS: A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. SUBJECTS AND METHODS: A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis. RESULTS: Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13). CONCLUSIONS: Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.