Operation theatre time utilization during emergency surgeries at a government institute of trauma in Karachi, Pakistan.

OBJECTIVE: To evaluate operation theatre time utilisation during emergency cases. METHODS: The prospective, observational study was conducted at the Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, from January 17 to April 17, 2020, during which the three dedicated emergency operating rooms at the centre were monitored for time from transferring the patient to the operation theatre till the patient was shifted out after surgery. Data was analysed using SPSS 24. RESULTS: Of the total 1,287 surgeries performed, 625(48.56%) were included. Of them, 373(59.7%) patients were shifted to the operation theatre once it was ready, while 252(40.3%) were shifted in advance. There were 474(75.8%) male patients, and 151(24.1%) were females. The overall mean age was 32.7±17.4 years (range: ≤1 year to ≥47 years). Mean time of patient transfer to the operating room was 1:17±1:52 hours:minutes. Delay was recorded in 133(35. 6%) cases who were shifted from location when the operation theatre was available. It was caused in 64(17.15%) cases by surgical teams, another emergency surgery in the operating room 24(6.4%) and operating room cleaning 19(5%). The mean waiting time in the holding area was 1:25±1:21hours:minutes, and mean time from induction to surgical incision was 0:34±0:32 hours:minutes. Delays was caused by trainee surgeons in 79(12.64%) cases, and prolonged preoperative patient preparation in 99(15.84%). Mean turnover time was 0:48±0:42 hours:minutes. Delay was caused by post-operative unavailability of ambulance transportation 29(15%), and intensive care unit bed availability 14(7.2%). CONCLUSIONS: Time utilisation of emergency operation theatres can be maximised by improved overall coordination.

Clinical Characteristics and Outcome of Patients With Severe COVID-19 Pneumonia at a Public Sector Hospital in Karachi, Pakistan.

INTRODUCTION: In Pakistan, the first case of COVID-19 was reported in February of 2020, cases peaked in June, and by January 2021, approximately 500,000 confirmed cases and over 10,000 deaths have been reported. There is a lack of data in Pakistan of the demographics, clinical characteristics, and outcome of patients with COVID-19 pneumonia, particularly those with severe illness, which we aim to assess. METHODS: This is a single-centered, observational study conducted at the COVID unit of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma in Karachi, Pakistan. A manual medical record review of patients admitted from April 24, 2020 to August 24, 2020 was conducted, and all patients with polymerase chain reaction (PCR) positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) with moderate, severe, and critical COVID-19 pneumonia were included. RESULTS: Of 299 patients, the median age was 60 years (50-65). Males accounted for 221 (73.9%). Most common symptoms were shortness of breath seen in 270 (90.3%) and fever in 225 (75.3%) patients. Diabetes mellitus (51.2%) and hypertension (50.3%) were the predominant co-morbidities. COVID disease was categorized on admission as moderate in 68 (22.7%), severe in 151 (50.5%), and critical in 80 (26.8%) patients. Survival analysis was done in 252 patients, all of whom received steroids, while tocilizumab was administered to 111 (44%) patients. Hundred (39.7%) patients received non-invasive ventilation (NIV), while 57 (22.6%) were placed on mechanical ventilation. Overall, 95 (37.7%) patients died. Factors associated with mortality included older age with those above 60 years more likely to die (odds ratio [OR]: 1.925; 95% CI: 1.148-3.228; pvalue: 0.009), presence of co-morbidities (OR 1.843; 95% CI: 0.983-3.456; p value: 0.070), development of cytokine release syndrome (CRS) (73 [56.2%] vs 57 [43.8%], p value: <0.001), acute kidney injury (31 [81.6%] vs 7 [18.4%], p value: <0.001), cardiac complications (12 [75%] vs 4 [25%], p value: 0.002), and sepsis (29 [87.9%] vs 4 [12.1%], p value: <0.001). Non-survivors were more likely to develop acute respiratory distress syndrome (ARDS), having been placed on NIV and mechanical ventilation. Laboratory parameters at final outcome found that in non-survivors, median total leukocyte count, C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) were higher, while absolute lymphocyte count and platelet counts were lower which were found to be statistically significant compared to survivors. CONCLUSION: In this study of patients with severe COVID-19 pneumonia at a public sector hospital in Karachi, Pakistan, most were males, and the average age was 60 years. Mortality was high, and associated factors included older age, presence of comorbid conditions, and the development of ARDS, CRS, and sepsis.

A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery.

BACKGROUND: Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries. METHODS: We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the presence of one of these features and the clinically identified need to administer antibiotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics. RESULTS: We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to original strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events. CONCLUSIONS: Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.).

Growing teratoma syndrome in ovarian germ cell tumours - a diagnostic challenge, two case reports.

Growing teratoma syndrome (GTS) is a rare complication of ovarian germ cell tumours and occurs in young age group. It is characterized by clinical or radiological increase in tumour size during or after chemotherapy, with normalization of tumour marker levels. Histopathological tissue growth post chemotherapy is a mature teratoma without any malignant component. Mainstay of treatment is surgical excision of the disease to prevent progression of tumour as mature teratomas are resistant to both chemotherapy and radiotherapy. Diagnosis is a challenge as disease recurrence or chemo-resistance can be difficult to distinguish. Benign nature of this disease entity is essential to avoid overzealous chemotherapy or radical surgery.

Prophylactic antibiotics to reduce pelvic infection in women having miscarriage surgery - The AIMS (Antibiotics in Miscarriage Surgery) trial: study protocol for a randomized controlled trial.

BACKGROUND: The estimated annual global burden of miscarriage is 33 million out of 210 million pregnancies. Many women undergoing miscarriage have surgery to remove pregnancy tissues, resulting in miscarriage surgery being one of the most common operations performed in hospitals in low-income countries. Infection is a serious consequence and can result in serious illness and death. In low-income settings, the infection rate following miscarriage surgery has been reported to be high. Good quality evidence on the use of prophylactic antibiotics for surgical miscarriage management is not available. Given that miscarriage surgery is common, and infective complications are frequent and serious, prophylactic antibiotics may offer a simple and affordable intervention to improve outcomes. METHODS: Eligible patients will be approached once the diagnosis of miscarriage has been made according to local practice. Once informed consent has been given, participants will be randomly allocated using a secure internet facility (1:1 ratio) to a single dose of oral doxycycline (400 mg) and metronidazole (400 mg) or placebo. Allocation will be concealed to both the patient and the healthcare providers. A total of 3400 women will be randomised, 1700 in each arm. The medication will be given approximately 2 hours before surgery, which will be provided according to local practice. The primary outcome is pelvic infection 2 weeks after surgery. Women will be invited to the hospital for a clinical assessment at 2 weeks. Secondary outcomes include overall antibiotic use, individual components of the primary outcome, death, hospital admission, unplanned consultations, blood transfusion, vomiting, diarrhoea, adverse events, anaphylaxis and allergy, duration of clinical symptoms, and days before return to usual activities. An economic evaluation will be performed to determine if prophylactic antibiotics are cost-effective. DISCUSSION: This trial will assess whether a single dose of doxycycline (400 mg) and metronidazole (400 mg) taken orally 2 hours before miscarriage surgery can reduce the incidence of pelvic infection in women up to 2 weeks after miscarriage surgery. TRIAL REGISTRATION: Registered with the ISRCTN (international standard randomised controlled trial number) registry: ISRCTN 97143849 . (Registered on April 17, 2013).

Assessing The Role Of Education In Adult Women's Knowledge And Awareness Of Human Papillomavirus And Human Papillomavirus Vaccine.

BACKGROUND: Awareness and knowledge of Human Papillomavirus (HPV) and HPV vaccine among women are not satisfactory in developing countries. The aim of this study was to assess the role of education in adult women about knowledge and awareness of human papillomavirus (HPV) and HPV vaccine. METHODS: This cross-sectional study was carried out in women aged 19- 50 years attending the out-patient waiting area of a tertiary care hospital in Karachi from August 2014 to August 2015. Convenience sampling was applied. After their written consent, a selfadministered questionnaire was used to obtain information regarding role of education and awareness, knowledge of human papillomavirus (HPV) and HPV vaccine. A total of 600 women completed the questionnaire. RESULTS: Mean age of the study participants was 39±10.7 years. About 68% (n=405) had an education level intermediate or less, while 33% (n=195) had a bachelors or higher degree. A total of 56.3% (n=338) women were aged less than 40 years. CONCLUSIONS: Awareness among women varies with the level of education acquired. As shown by results, a lesser proportion of undergraduate women were aware about HPV and its related diseases as compared women at graduate level. Moreover, our study identifies significant gaps in knowledge about sexually transmitted infections, HPV, cervical cancer and its prevention. There is an urgent need to develop public awareness programs targeting the adolescent and young adult women of our country.

Comparison of foeto-maternal outcome in pregnant women with hepatitis E - A review of 12 years.

OBJECTIVE: To compare adverse maternal and foetal outcome in pregnant women with hepatitis E immunoglobulin M reactive versus non-reactive. METHODS: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised records of pregnant patients at any gestational age with clinical and biochemical evidence of hepatitis E from January 2002 and December 2014. . Maternal and perinatal outcome of the subjects were analysed. SPSS 20 was used for data analysis. RESULTS: Out of the 200 subjects, 168(84 %) were hepatitis E immunoglobulin M reactive and 32(16%) were non-reactive. The overall mean age was 26.7±4.5 years. Also, 12(7%) patients in the immunoglobulin M reactive group were admitted to intensive care unit compared to no one from the non-reactive group. Similarly fulminant hepatic failure was seen in 12(7.1%) patients in the immunoglobulin M reactive group compared to no one in the other group. Post-partum haemorrhage was more frequent in the immunoglobulin M reactive group compared to the non-reactive group. There were 5(3%) maternal deaths in the reactive group compared to no death in the other group. Moreover, 34(20.2%) neonates of the immunoglobulin M reactive group needed neonatal intensive care unit admission compared to none in the non-reactive group. There were 4(2.4%) neonatal deaths in the reactive group. CONCLUSIONS: Participants in the immunoglobulin M reactive group had a higher percentage of adverse foeto-maternal outcomes compared to the non-reactive group.

Intracardiac echogenic focus and fetal outcome - review of cases from a tertiary care centre in Karachi, Pakistan.

OBJECTIVE: To study the outcome in fetuses with intracardiac echogenic focus (ICEF) at the time of second trimester scan. METHODS: All women with the sonographic findings of ICEF from January 2009 to December 2010 were included in this retrospective study. RESULTS: ICEF were found in 71 out of 8226 screened (0.86%) women. Mean maternal age in the population was 26.9 ± 3.9 years. Foci were the isolated marker in 69 (97%) cases. In two cases there were additional findings of choroid plexus cysts. A fetal echocardiograph was done only in 13 (18.3%) patients. Majority of these pregnancies (95.7%) had a normal outcome. Postnatal echocardiograph was performed in 11 neonates (15%) out of which one had a small VSD, and in another case Tetralogy of Fallot was found. In addition, Pulmonary artery hypertension was diagnosed in one case. There was one intrauterine fetal demise and two neonatal deaths in this cohort. CONCLUSIONS: The prevalence of ICEF was 0.86% in our study population. About 95.77% of these cases had an uncomplicated perinatal outcome. It was an isolated finding in almost all cases. These findings will be helpful in counseling parents in our setting.

Pregnancy loss rate following amniocentesis.

OBJECTIVE: To determine pregnancy loss rate following amniocentesis in a mainstream urban healthcare centre. METHODS: We analysed cases of all pregnant women who underwent Amniocentesis at the Foetal Medicine Unit of Aga Khan University Hospital, Karachi, during 2001 to 2010. Cases of unknown pregnancy outcome were excluded, and after the process of consent, the final study population was 228 patients. Two operators performed the procedure using 22 G needle. RESULTS: The mean age of women in the study was 32 +/- 6 years. The commonest indication of the procedure was a previous baby with Down's Syndrome. Majority 197 (86.6%) cases had a normal karyotype. Down's syndrome was 14 (6.1%). Regarding the outcome of pregnancies, it was normal in 173 (77.3%) cases while 2 (0.8%) intrauterine deaths were reported, one of which was within two weeks of the procedure. The number of pregnancy termination was 27 (11.7%). There was one miscarriage which means the pregnancy loss rate in the study population was 0.4%. CONCLUSION: In order to have good quality control, healthcare audits are essential on both short-term and long-term basis.