Disparate outcomes of global emergency surgery - A matched comparison of patients in developed and under-developed healthcare settings.

INTRODUCTION: Access to surgical care is an essential element of health-systems strengthening. This study aims to compare two diverse healthcare settings in South Asia and the United States (US). METHODS: Patients at the Aga Khan University Hospital (AKUH), Pakistan were matched to patients captured in the US Nationwide Inpatient Sample (US-NIS) from 2009 to 2011. Risk-adjusted differences in mortality, major morbidity, and LOS were compared using logistic and generalized-linear (family gamma, link log) models after coarsened-exact matching. RESULTS: A total of 2,244,486 patients (n = 4867 AKUH; n = 2,239,619 US-NIS) were included. Of those in the US-NIS, 990,963 (42.5%) were treated at urban-teaching hospitals, 332,568 (14.3%) in rural locations. Risk-adjusted odds of reported mortality were higher for Pakistani patients (OR[95%CI]: 3.80[2.68-5.37]), while odds of reported complications were lower (OR[95%CI]: 0.56[0.48-0.65]). No differences were observed in LOS. The difference in outcomes was less pronounced when comparing Pakistani patients to American rural patients. CONCLUSION: These results demonstrate significant reported morbidity, mortality differences between healthcare systems. Comparative assessments such as this will inform global health policy development and support.

Teaching children road safety through storybooks: an approach to child health literacy in Pakistan.

BACKGROUND: Road traffic injuries (RTIs) commonly affect the younger population in low- and-middle-income countries. School children may be educated about road safety using storybooks with colorful pictures, which tends to increase the child's interest in the text. Therefore, this study assessed the use of bilingual pictorial storybooks to improve RTI prevention knowledge among school children. METHODS: This pretest-posttest study was conducted in eight public and nine private schools of Karachi, Pakistan, between February to May 2015. Children in grades four and five were enrolled at baseline (n = 410). The intervention was an interactive discussion about RTI prevention using a bilingual (Urdu and English) pictorial storybook. A baseline test was conducted to assess children's pre-existing knowledge about RTI prevention followed by administration of the intervention. Two posttests were conducted: first immediately after the intervention, and second after 2 months. Test scores were analyzed using McNemar test and paired sample t-test. RESULTS: There were 57% girls and 55% public school students; age range 8-16 years. Compared to the overall baseline score (5.1 ± 1.4), the number of correct answers increased in both subsequent tests (5.9 ± 1.2 and 6.1 ± 1.1 respectively, p-value < 0.001). Statistically significant improvement in mean scores was observed based on gender, grades and school type over time (p-value < 0.001). CONCLUSION: Discussions using bilingual pictorial storybooks helped primary school children in Pakistan grasp knowledge of RTI prevention. RTI education sessions may be incorporated into school curricula using storybooks as teaching tools. Potential exists to create similar models for other developing countries by translating the storybooks into local languages.

Influence of sub-specialty surgical care on outcomes for pediatric emergency general surgery patients in a low-middle income country.

BACKGROUND: Whether adult general surgeons should handle pediatric emergencies is controversial. In many resource-limited settings, pediatric surgeons are not available. The study examined differences in surgical outcomes among children/adolescents managed by pediatric and adult general surgery teams for emergency general surgical (EGS) conditions at a university-hospital in South Asia. METHODS: Pediatric patients (<18y) admitted with an EGS diagnosis (March 2009-April 2014) were included. Patients were dichotomized by adult vs. pediatric surgical management team. Outcome measures included: length of stay (LOS), mortality, and occurrence of ≥1 complication(s). Descriptive statistics and multivariable regression analyses with propensity scores to account for potential confounding were used to compare outcomes between the two groups. Quasi-experimental counterfactual models further examined hypothetical outcomes, assuming that all patients had been treated by pediatric surgeons. RESULTS: A total of 2323 patients were included. Average age was 7.1y (±5.5 SD); most patients were male (77.7%). 1958 (84.3%) were managed by pediatric surgery. The overall probability of developing a complication was 1.8%; 0.9% died (all adult general surgery). Patients managed by adult general surgery had higher risk-adjusted odds of developing complications (OR [95%CI]: 5.42 [2.10-14.00]) and longer average LOS (7.98 vs. 5.61 days, p < 0.01). 39.8% fewer complications and an 8.2% decrease in LOS would have been expected if all patients had been managed by pediatric surgery. CONCLUSION: Pediatric patients had better post-operative outcomes under pediatric surgical supervision, suggesting that, where possible in resource-constrained settings, resources should be allocated to promote development and staffing of pediatric surgical specialties parallel to adult general surgical teams.

Do delays in surgery affect outcomes in patients with inter-trochanteric fractures?

OBJECTIVE: To study the differences in outcomes of early versus delayed surgery in patients with intertrochanteric fractures. METHODS: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients who underwent surgery for intertrochanteric hip fractures from 2005 to 2010. A gap of >48hours between the event and the surgery was considered a delayed procedure and its impact on outcome was assessed. RESULTS: Of the 190 patients, 138(72.6%) were in the early group and 52(27.3%) in the delayed group. The most common cause for delay of surgery was electrolyte imbalance in 14(27%) patients. Patients with delayed surgery had more comorbidites and higher ASA grades compared to those that underwent early surgery (p<0.05). Inpatient mortality was significantly higher in the delayed group (p=0.006). Multivariate analysis showed that higher mortality was associated with delay in surgery. CONCLUSIONS: In patients with multiple comorbid conditions, expedited optimisation for surgery may be warranted to reduce mortality.

Effect of L-type calcium channel blocker (amlodipine) on myocardial iron deposition in patients with thalassaemia with moderate-to-severe myocardial iron deposition: protocol for a randomised, controlled trial.

INTRODUCTION: Sideroblastic cardiomyopathy secondary to repeated blood transfusions is a feared complication in thalassaemia. Control of myocardial iron is thus becoming the cornerstone of thalassaemia management. Recent evidence suggests a role for L-type Ca(2+) channels in mediating iron uptake by the heart. Blocking the cellular iron uptake through these channels may add to the benefit of therapy to standard chelation in reducing myocardial iron. We aim to determine the efficacy of amlodipine (a calcium channel blocker) as an adjunct to standard aggressive chelation in retarding myocardial iron deposition in thalassaemics with or without cardiomyopathy. OUTCOMES: The primary outcome is to compare the efficacy of amlodipine+chelation (intervention) versus standard chelation (control) in retarding myocardial iron deposition. Secondary outcomes include the effect of amlodipine therapy on systolic and diastolic function, strain and strain rate and liver iron content. METHODS AND ANALYSIS: This is a single-centre, parallel-group, prospective randomised control trial. Twenty patients will be randomised in a 1:1 allocation ratio into the intervention and control arms. In addition to conventional echocardiography, MRI T2* values for assessment of cardiac and liver iron load will be obtained at baseline and at 6 and 12 months. Cardiac T2* will be reported as the geometric mean and per cent coefficient of variation, and an increase in cardiac T2* values from baseline will be used as an end point to compare the efficacy of therapy. A p Value of <0.05 will be considered significant. STUDY SETTING: Department of Pediatric and Child Health, Aga Khan University Hospital, Karachi, Pakistan. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Review Committee and Clinical Trials Unit at The Aga Khan University with respect to scientific content and compliance with applicable research and human subjects regulations. Findings will be reported through scientific publications and research conferences and project summary papers for participants. TRIAL REGISTRATION NUMBER: ClinicalTrials.Gov. Registration no: NCT02065492.

Attitudes of medical students towards incentives offered by pharmaceutical companies -- perspective from a developing nation -- a cross-sectional study.

BACKGROUND: A training physician has his first interaction with a pharmaceutical representative during medical school. Medical students are often provided with small gifts such as pens, calendars and books, as well as free lunches as part of drug promotion offers. Ethical impact of these transactions as perceived by young medical students has not been investigated in Pakistan before. This study aimed to assess the association of socio-demographic variables with the attitudes of medical students towards pharmaceutical companies and their incentives. METHODS: As part of a cross-sectional survey, a validated questionnaire previously used for assessing attitude of medical students towards pharmaceutical industry, was modified, pre-tested and distributed among consenting clinical year students at DUHS and AKU. Questions included acceptability of pharmaceutically sponsored gifts, events and tuition fee, and their impact on future prescription. Responses were graded as agree, disagree or neutral which were then scored according to the AMSA guidelines of ethical conduct. RESULTS: Out of a total of 353 targeted students 303 responded, corresponding to a response rate of 85.8%. Responses indicated that 42.7% students believed in no interaction with drug companies during medical school. However, 81% of students favored pharmaceutical sponsorship of student-body events/seminars at medical colleges. More than one-third of the students were comfortable receiving gifts from drug companies. Overall, the results of this study offer an interesting comparison between the students of a private medical school (AKU) and a public medical school (DUHS); AKU students exhibited a greater degree of mistrust towards drug information provided by pharmaceutical companies compared to DUHS students (p = 0.040). Furthermore, when asked if there was a need to incorporate guidelines in the undergraduate curriculum with regard to interaction with drug companies, 84.2% students at AKU agreed, compared to 54.9% at DUHS. Medical student Attitude Scores are more or less similar to each other independent of their various demographical differences. CONCLUSION: This study highlights that medical students in our population have a high level of acceptability towards incentives offered by pharmaceutical industry and that formal guidance regarding the subject should be incorporated into medical curriculum.

Hip fracture surgery: does type of anesthesia matter?

BACKGROUND: Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated. METHODS: In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered. RESULTS: During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia (1.25 ± 0.39 hrs) as compared to those who received general anesthesia (1.54 ± 0.6 hrs) (P < 0.05). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups. CONCLUSION: Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.

Resident work hour reforms: implications regarding hip fracture surgery.

BACKGROUND: Resident work hour reforms were developed by Aga Khan University Postgraduate Medical education committee in the year 2005. These reforms were implemented by the section of Orthopedics in winter 2006. We designed this study to determine if there is a difference in morbidity and mortality following Dynamic Hip Screw (DHS) fixation for intertrochanteric fracture patients before and after implementation of work hour reforms. METHODS: Patients who underwent DHS fixation for inter-trochanteric fracture from January 2005 to December 2008 were included. These patients were divided into two groups. Group A included those patients who underwent DHS fixation prior to the implementation of work hour reforms and Group B patients had their hip fracture surgery after the implementation of these reforms. RESULTS: The mean operative time was 1.6±0.6 h and 1.3±0 h for group A and B patients respectively (p<0.001). There was no change in the rates of wound infection, length of hospital stay, post operative ambulation status, inadequate fixation, repeat surgeries and mortality in the two groups. CONCLUSION: Resident work hour reform was associated with a significant decrease in the mean operative time for patients undergoing DHS fixation. However morbidity and mortality following DHS fixation for Intertrochanteric fractures has not decreased after implementation of these reforms. Further research evaluating patient outcomes in orthopedic surgery following work-hour restrictions are needed. Moreover, the impact of these reforms on the educational and research activities of the residents also needs to be determined.

Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder.

Pulmonary talcosis is a rare but debilitating variant of pneumoconiosis often presenting with isolated non-specific symptoms of progressive exertional dyspnoea or cough. Occupational exposure to talc dust and intravenous drug abuse are well-recognised aetiological factors with only a few cases related to cosmetic talc exposure being reported to date. The authors report a case of a young woman in whom a mere 4 month ritual of inhaling cosmetic talcum powder led to full-blown pulmonary talcosis being diagnosed 10 years later. The importance of a taking a pertinent history relating to environmental exposures in all patients presenting with respiratory symptoms is re-established here.