Training in cardiothoracic surgery: The role for simulation.

Adequate cardiothoracic surgical training is essential for provision of quality care to patients. In recent years, simulation-based training has been advocated as an adjunct to traditional surgical training. Advances in simulation technology has resulted in many low- and highfidelity simulators being employed in cardiothoracic surgical training. Such models allow trainees to practice an array of realistic full-length procedures in a safe and controlled environment, with the window to make mistakes and consider them learning points. There is significant evidence to demonstrate the effectiveness of cardiothoracic surgery simulation in improving surgical skills and operating room performances in addition to building confidence among trainees. However, owing to the high financial cost of arranging it, simulation-based training is not widespread in low- and middle-income countries, including Pakistan. More work is warranted on the cost effectiveness of implementing simulation-based learning, which, in turn, would increase the uptake of simulation to enhance cardiothoracic surgical training in Pakistan.

Novel data visualization and risk analytic algorithm in a low-middle income country.

To discuss the use of T3™, a data aggregation, visualization, and risk analytic platform in a single centre and its framework for implementation of such a tool in clinical care. We share experience of a tool implemented in a tertiary care Intensive Care Unit (ICU) with limited resources. Superusers were identified and trained. Implementation involved monitoring, evaluation, and user engagement data for continuous emphasis on the use of this tool. Persistent display of T3 data enhanced nursing operational efficiency. Its use was expanded to use in nurses rounds and handover, mortality and morbidity meetings, clinical team teaching through selected teaching cases and analysis of stored data with different research questions. However, lack of infrastructure and technological comprehension, paucity of multidisciplinary teams makes it a challenge in its implementation. Clear framework of implantation and pre-designed studies to determine the clinical usage and effectiveness are important for wide-spread use of such tools.

Magnetic Hydroxyapatite Nanoparticles in Regenerative Medicine and Nanomedicine.

This review focuses on the latest advancements in magnetic hydroxyapatite (mHA) nanoparticles and their potential applications in nanomedicine and regenerative medicine. mHA nanoparticles have gained significant interest over the last few years for their great potential, offering advanced multi-therapeutic strategies because of their biocompatibility, bioactivity, and unique physicochemical features, enabling on-demand activation and control. The most relevant synthetic methods to obtain magnetic apatite-based materials, either in the form of iron-doped HA nanoparticles showing intrinsic magnetic properties or composite/hybrid compounds between HA and superparamagnetic metal oxide nanoparticles, are described as highlighting structure-property correlations. Following this, this review discusses the application of various magnetic hydroxyapatite nanomaterials in bone regeneration and nanomedicine. Finally, novel perspectives are investigated with respect to the ability of mHA nanoparticles to improve nanocarriers with homogeneous structures to promote multifunctional biological applications, such as cell stimulation and instruction, antimicrobial activity, and drug release with on-demand triggering.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

INTRODUCTION: Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. METHODOLOGY: A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. RESULTS: Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). CONCLUSION: Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Autologous vein graft repair of mycotic innominate artery aneurysm: A case report.

INTRODUCTION: Innominate artery aneurysm (IAA) is an extremely rare fatal condition with an overall prevalence of less than 3 % of all supra-aortic artery aneurysms. These infrequent lesions usually present as an emergency and require challenging surgical procedures. CASE PRESENTATION: We report an interesting case of mycotic IAA in a 25 years old male patient. He was a known intravenous drug abuser having mycotic aneurysm arising from brachiocephalic artery with eccentric thrombus causing adjacent mass effect over the trachea. He underwent successful emergent surgical management of aneurysm with autologous vein graft using superficial femoral vein. Unfortunately, he died due to massive upper gastrointestinal bleeding leading to multi-organ failure after a prolonged post-operative course. CLINICAL DISCUSSION: Mycotic aneurysms of the IA are extremely rare with an overall incidence of 1-2.7 % cases of all IAA. Presentation of the IAA can be quite variable from asymptomatic to symptoms exhibiting mass effect over surrounding structures. Rupture of IAA can be fatal and can occur if not treated promptly. There are no current recommendations or guidelines for treatment and interventions in IAA. Surgical management involves complete excision of the aneurysm and then revascularization. CONCLUSION: Infected Innominate artery aneurysm is a rare surgical entity requiring early diagnosis, detailed investigation and prompt surgical management involving multidisciplinary team approach. Our case describes a relatively innovative approach to this scarce condition.

Disparities in access to quality surgical care for women in resource-constrained settings: Bottlenecks and the way forward.

Women seeking surgical care are burdened with gender disparities, particularly in resource-limited settings. Such disparities can lead to women often presenting late with advanced disease and poor prognoses. The current narrative review was planned to find evidence for gender disparities, their implications, challenges faced by women seeking surgical care, and strategies to address them. Potentiating from interplay between various societal, sociocultural, and economic barriers, the main challenges included inadequate autonomy, financial constraints, transport and referral issues, lack of experienced women surgeons, privacy concerns, surgeon distrust, and higher thresholds for seeking care. While research revealed these underlying causes, much work remains for governmental healthcare bodies, the international community, surgical leadership, policymakers, surgeons, and family members of patients to act on the highlighted issues. Unrestricted access to quality surgical care for everyone is of vital importance, and can translate into a significant decrease in preventable disabilities and deaths among women in resource-constrained settings.

Radial artery coronary bypass grafting: Surgical outcomes of an unexplored innovation in a developing country.

OBJECTIVE: To explore postoperative outcomes, particularly prolonged length of hospital stay, in radial artery coronary artery bypass graft patients in a tertiary-care setting. METHODS: The pilot prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to September 2020, and comprised adult patients of either gender due to undergo coronary artery bypass grafting for coronary artery disease involving two or more vessels. The subjects were approached for the use of their radial artery as a conduit. Prolonged length of hospital stay was defined as postoperative stay >9 days. Multivariable logistic regression was used to identify independent predictors of the length of hospital stay. Data was analysed using SPSS 21. RESULTS: Of the 97 patients, 84(86.6%) were males. The overall mean age of the sample was 58.33±8.34 years. Mean length of hospital stay was 8.10±2.37 days, and 23(23.7%) patients had prolonged stay. Higher age was a significant predictor of prolonged hospital stay (p<0.05). Besides, 23(23.7%) patients developed acute kidney injury. There was no incidence of wound, infection or deep venous thrombosis, while 1(1.03%) patient had to be reopened due to excessive postoperative bleeding, and it represented the lone mortality. CONCLUSIONS: Patient age was found to be a significant predictor of prolonged hospital stay in patients undergoing radial artery coronary artery bypass graft, while almost a quarter of the sample was affected by acute kidney injury.

Perioperative registries in resource-limited settings: The way forward for Pakistan.

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical records and high loss-to-follow-up rates, requiring telemedicine initiatives as an adjunct to existing care for the assessment of post-discharge outcomes. Lastly, standardised coding of clinical terminology is warranted for ensuring interoperability of the registries for which adaptation of the existing disease and procedural codes can be a sustainable and cost-effective alternative to the development of new codes.

Path to publication: A peer mentorship model for student-lead surgical research.

Early and sustained involvement in research is imperative for medical students to ensure better career prospects in addition to provision of high-quality, evidence-based care to patients. However, involvement of students in surgical research still remains limited, owing to inadequate research training. The current paper was planned to describe the structure of the "Path to Publication" series, incorporating peer mentorship with capacity-building research workshops for medical students. A total of 25 students were grouped into 8 surgical subspecialty groups to conduct research, supervised by experienced student research and faculty mentors. In addition, a series of research workshops were organized in synchronization with the different phases of research for all groups, equipping medical students with the necessary skills needed for each phase. This initiative has successfully equipped medical students with research skills in addition to involving them in surgical research, helping to advance their research careers and promote evidence-based surgery in Pakistan.

Harassment and mental health in surgical training: a pilot survey of surgical trainees in Pakistan.

OBJECTIVE: To assess harassment among surgical trainees and its effects on mental health, and to explore its association with gender. METHODS: The nationwide cross-sectional pilot study was conducted by the Association of Women Surgeons of Pakistan from July to September 2019, and included surgical trainees of either gender working in both public and private hospitals. Data was collected using an anonymous online survey form to assess harassment and self-perceived burnout and depression. Data was analysed using SPSS 22. RESULTS: Of the 147 respondents, 49(33.3%) were males; 98(66.6%) were females; and 118(80.3%) were residents. Workplace harassment was reported by 80(54.4%) trainees. Among the males it was reported by 24(49%) and among the females by 56(57%) (p=0.349). Of those having faced harassment, 9(11.3%) reported it to the administration. Severe self-perceived burnout was reported by 102(69.4%) respondents, and severe self-perceived depression by 69(46.9%). Respondents experiencing bullying were more likely to report severe self-perceived burnout than those not experiencing bullying (p=0.02). Multivariable logistic regression showed female gender to be significantly associated with sexual harassment (odds ratio: 4.261 [95% confidence interval: 1.067-17.019]) and severe self-perceived depression (odds ratio: 5.052 [95% confidence interval: 1.187-21.503]). Need for a support group was identified by 134(91.2%) trainees. CONCLUSIONS: An overwhelming need was found for trainee surgeon support groups and other interventions targeted at improving the workplace environment for surgical trainees in Pakistan.

Surgical Education and Training during the COVID-19 Pandemic: Strategies and Solutions for Pakistan.

The coronovirus disease-2019 pandemic has severely impacted surgical education and training in Pakistan and worldwide, causing problems, such as risk of infection, limited hands-on training, examination delays, and trainee redeployment to non-surgical specialties. The current review was planned to describe innovative strategies adopted by surgical training programmes worldwide in order to suggest comprehensive recommendations at the level of the College of Physicians and Surgeons Pakistan and individual institutions to counter the challenges presented by the pandemic in Pakistan. The innovative use of technology, including open-access online educational portals, virtual educational activities and simulation-based learning, can help reform education delivery during the pandemic. Hospitals' implementation of "shift schedules" for rotations helps continue training while minimising risks. Moreover, examination boards and residency programmes must appropriately tailor their eligibility criteria and assessment processes to the current situation. Lastly, it is vital to safeguard trainees' mental wellness during the pandemic and after by ensuring readily available professional psychological support when needed.

Factors Affecting Women Surgeons' Careers in Low-Middle-Income Countries: An International Survey.

BACKGROUND: Despite increasing numbers of women surgeons globally, barriers to career advancement persist. While these barriers have been extensively discussed in high-income countries (HICs), the topic has received minimal attention in lower-middle-income countries (LMICs) like Pakistan. METHODS: The Association of Women Surgeons of Pakistan (AWSP)-an organization in Pakistan consisting of female surgeons and trainees-carried out this international cross-sectional study over July-Sept 2019. An anonymous online survey was disseminated via social media platforms and various institutions across Pakistan and internationally. RESULTS: A total of 218 female surgeons responded to the survey, with 146 (67%) from Pakistan and 72 (33%) from HICs. While HIC surgeons were more likely to report gender discrimination/bias (GD/bias) during residency (29.2% vs 11.6%; p = 0.001), more Pakistani surgeons reported that GD/bias negatively affected their job satisfaction (80.7% vs. 64.9%; p = 0.024). GD/bias manifested most commonly as differences in mentoring relationships (72%). A higher percentage Pakistani surgeons reported having experienced a family-related interruption in their career (24.7% vs. 11.1%; p = 0.019). The vast majority (95%) felt that surgery was perceived as a masculine field, and the majority (56.4%) of respondents reported having been told that they could not be a surgeon because of their gender. CONCLUSION: Our study highlights keys factors that must be addressed to provide equal career opportunities to women surgeons. It is the responsibility of surgical educators, policy makers, and healthcare organizations to facilitate women surgeons' career progression by developing systems that support equitable career growth for women surgeons.

Wet labs: A useful tool in training surgical residents in a third world country.

•Wet labs are a useful, cost-effective and safe tool in teaching of Cardiothoracic Surgery residents.•In a third world country where advance real life simulators are not available.•It improves resident's tissue handling and surgical skills.•Allows faculty members to give continuous feedback to their residents.

Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country.

INTRODUCTION: Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan. METHOD: A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons. RESULTS: 98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported 'significant' frequency of GD/bias during residency. A higher percentage of women reported 'insignificant' frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p < 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p < 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty. CONCLUSION: Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as "significant". Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research.

Cultural Barriers for Women in Surgery: How Thick is the Glass Ceiling? An Analysis from a Low Middle-Income Country.

BACKGROUND: This study aimed to highlight cultural barriers faced by surgeons pursuing a surgical career faced by surgeons at a tertiary care hospital in Pakistan. As more females opt for a surgical career, barriers faced by female surgeons are becoming increasingly evident, many of which are rooted in cultural norms. In Pakistan, a predominantly Muslim-majority, low middle-income country, certain societal expectations add additionally complexity and challenges to existing cultural barriers. METHODS: A cross-sectional survey was administered via e-mail to the full-time faculty and trainees in the Department of Surgery at the Aga Khan University Hospital, Karachi, Pakistan, from July 2019 to November 2019. RESULTS: In total, 100 participants were included in this study, with the majority being residents (55.6%) and consultants (33.3%). 71.9% of female surgeons felt that cultural barriers towards a surgical career existed for their gender, as compared to 25.4% of male surgeons (p < 0.001). 40.6% of females reported having been discouraged by family/close friends from pursuing surgery, as compared to only 9.0% of males (p < 0.001). Moreover, a greater percentage of females surgeons were responsible for household cooking, cleaning and laundry, as compared to male surgeons (all p < 0.001). Lastly, 71.4% of female surgeons felt that having children had hindered their surgical career, as compared to 4.8% of males (p < 0001). CONCLUSION: Our study shows that significant cultural barriers exist for females pursuing a surgical career in our setting. Findings such as these emphasize the need for policy makers to work towards overcoming cultural barriers.

Aberrant right subclavian artery with atrial septal defect: Simultaneous repair via median sternotomy.

INTRODUCTION: Aberrant right subclavian artery, also known as arteria lusoria, is one of the rarer congenital vascular malformations of the left sided aortic arch which arises distal to the left subclavian artery, following a retroesophageal course to the right side causing compression of the trachea or esophagus and resulting in a variety of symptoms most commonly dysphagia. PRESENTATION OF CASE: We report a case of a two and a half year old child who was diagnosed as having as having an aberrant right subclavian artery with an ostium secundum atrial septal defect and underwent simultaneous repair of both conditions via a median sternotomy. DISCUSSION: Aberrant right subclavian artery (ARSA) has a prevalence of 1.8 % and most commonly presents in fourth or fifth decade of life. Various surgical approaches have been described to repair this anomaly over the past years, each with its own limitations and complications. However, the median sternotomy approach provides adequate exposure during division and re-implantation of the vessel and simultaneously allows repair of any intra-cardiac defect. CONCLUSION: We believe that the best exposure for the correction of aberrant right subclavian artery is via a median sternotomy, especially in pediatric patients associated with other cardiac anomalies.

Traumatic aortic transection repair with distal perfusion - single center experience.

Blunt aortic injury is associated with significant mortality. A large number of patients lose their lives before reaching the hospital, those who survive half die within a day. Isthmus is the commonest site of aortic injury. Aortic injury is usually associated with other injuries of the body hence a multidisciplinary approach is required. For aortic transection the treatment options have evolved from proximal and distal aortic cross clamping and repair with distal perfusion technique using shunt or partial heart bypass (extracorporeal circulation) to endovascular stenting depending upon the available facilities andexpertise. Distal perfusion technique helps in avoiding paraplegia. We present our institutional experience of polytrauma associated with blunt aortic injuries managed with open surgical repair with distal perfusion using cardiopulmonary bypass.

Solitary fibrous pleural tumor. A rare and challenging case.

INTRODUCTION: Solitary fibrous tumor of the pleura (SFTP) is a rare tumor originating from mesenchymal tissue underlying the mesothelial pleural layer with only a limited number of reported cases. Benign and malignant SFTP usually appear as a well-defined, homogeneous, and rounded mass on imaging. Complete en bloc is usually the treatment of choice. CASE PRESENTATION: 44 years old gentleman presented with the unintentional weight loss and chest discomfort for 6 months. A CT scan of chest showed a 30 × 20 × 20 cm heterogeneously enhancing soft tissue mass involving the entire right hemithorax. PET scan showed a localized disease. Therefore, a complete right upper lobectomy and complete removal of mass was done, that resulted in complete expansion of the middle and lower lobe. The patient remains stable till date. Biopsy revealed a fibrous pleural tumor. CONCLUSION: Complete surgical resection of the tumor is usually sufficient, but there are reported cases with recurrence. Wedge resection for complete excision can be carried out for tumors arising from visceral pleura. Extra pleural excision can be done without chest wall resection in tumors arising from the parietal pleura.