COVID-19 Testing Crisis Management Through a Public-Private Partnership in Sindh, Pakistan.

As the coronavirus disease (COVID-19) pandemic spread, meeting the testing needs to control the spread of infection became a major challenge worldwide. In Pakistan, the lack of the requisite infrastructure and training compounded the acute shortage of testing kits and other consumables. Against this backdrop and to urgently improve province-wide access to high-quality COVID-19 polymerase chain reaction (PCR) testing with rapid turnaround times, the Government of the Sindh (GoS) province of Pakistan entered into a public-private partnership with Indus Hospital & Health Network (IHHN). Under this partnership, the GoS undertook sample collection and Indus Hospital in Karachi, Sindh, centralized testing. We describe the implementation strategies adopted by the partnership, as well as the challenges, opportunities, and lessons learned. Notably, up to 40% and 22% of total COVID-19 PCRs done in Sindh in the first 2 months of the pandemic, respectively, were performed at Indus Hospital in Karachi, though this percentage declined gradually as other centers caught up with their testing capacities. The rapid scaling up was achieved through a combination of mechanisms and factors including building on preexisting partnerships between the GoS and IHHN, pooling resources and harnessing distinct and complementary roles, relocating existing resources, introducing automation and information technology system changes, establishing risk mitigation strategies, and introducing quality measures within testing processes. The primary outcome of the partnership was rapid province-wide access to quality COVID-19 PCR testing with short turnaround times and at no cost to the patient. Furthermore, implementation of the partnership goals established new mechanisms as well as strengthened existing ones to enable rapid response to the future global health security challenges in Sindh, Pakistan.

Dissection of Ascending Aorta After Aortic Valve Replacement and Reduction Aortoplasty.

A case of Debakey type-II (Stanford type-A) dissecting aortic aneurysm, after aortic valve replacement and reduction aortoplasty, is reported. The patient was 35 years male who was diagnosed of severe aortic regurgitation along with aortic root dilatation of 7 cm. He underwent aortic valve replacement with 27-ASt Jude's mechanical aortic valve along with reduction aortoplasty. Nine months later, he was admitted to our hospital with complaint of severe sudden anterior chest pain. Computed tomography with aortic enhancement showed dilatation and dissection of ascending aorta. Successful operation of aortic root replacement with composite graft was performed and patient was discharged without any postoperative complication. The aortic diameter at the time of aortic valve replacement is an independent risk factor for the late aortic dissection.

Predictors of Mortality in Patients Undergoing Mitral Valve Replacement.

OBJECTIVE: Although mitral valve replacement is frequently performed in patients of all age groups, there are few studies available which determine the causes of operative mortality in mitral valve replacement especially in our region. Therefore, the objective of this study was to identify factors that are significantly associated with operative mortality in mitral valve replacement. METHODS: From August 2012 to March 2013, 80 consecutive patients undergoing mitral valve replacement in a single tertiary hospital were included. Patients with a history of previous coronary artery bypass graft surgery or congenital heart problems were excluded from the sample. The included patients were observed for a period of 30 days. Pre and post-operative variables were used to identify significant predictors of mortality. RESULTS: The overall hospital mortality (30 days) was 15%. High post-perative creatinine (P =0.05), high ASO titre (P=0.03), young age (P=0.011), low cardiac output (P=0.0001), small mitral valve size (P=0.002) and new onset of atrial fibrillation (P=0.007) were the significant independent predictors of operative morality. CONCLUSION: Mitral valve replacement can be performed in third world countries with limited resources with low mortality. However, optimal selection of mitral valve size can help to improve operative mortality.

Prosthetic valve thrombosis in a patient with mitral valve replacement.

Prosthetic valve thrombosis within one year after mitral valve replacement is rarely seen in patients on warfarin therapy and without any risk factor. Here, we describe a case of a 39-year- old female, who presented with dyspnoea and shortness of breath 11 months after mitral valve replacement. The echocardiogram revealed severe valvular stenosis due to presence of clots on the mitral valve and restricted motion of the mitral leaflets. As a result of deterioration of general condition and haemodynamic un-stability, plan was made to re-operate for her valve replacement surgery. This case report highlights the diagnosis, prevention and management of patients with prosthetic valve thrombosis following mitral valve replacement.

Post angioplasty coronary artery bypass grafting in patient with myasthenia gravis.

A 62 years old patient developed myasthenia gravis 2 years after his percutaneous coronary intervention. He was advised thymectomy for myasthenia gravis. During his cardiological evaluation, he was incidentally diagnosed to have 3 vessel disease. Hence, a simultaneous surgical intervention was performed consisting of thymectomy and CABG via standard cardiopulmonary bypass through median sternotomy. Previous medical history of diabetes and corticosteroid therapy made the patient immunocompromised. Therefore, a careful overall therapeutic strategy was devised to prevent mediastinitis. After his thymectomy and coronary artery bypass grafting, he was extubated within 6 hours. Plasmapheresis was done one day before the surgery and on first postoperative day. His medications for myasthenia gravis (pyridostigmine and prednisolone) were not stopped before and after the surgery. Patient was discharged on 6th postoperative day without any complications. On his follow-up 6 weeks postoperatively, his condition was unremarkable.

Effect of aspirin on postoperative bleeding in coronary artery bypass grafting.

PURPOSE: It is not uncommon for aspirin therapy to be withheld before coronary artery bypass grafting (CABG) because it is thought to increase the risk of postoperative bleeding. Many studies have shown that continued aspirin therapy reduces postoperative myocardial infarction and increases survival. The purpose of this study is to analyze the effect of preoperative aspirin on postoperative bleeding in patients undergoing CABG. MATERIAL AND METHODS: Patients (n=30) undergoing CABG were divided into two groups, group 1 (n=15) who received aspirin till the day of surgery, and group 2 in whom aspirin was stopped 5 days before surgery. Postoperative bleeding up to 76 h (approximately 3 days) was noted in both groups. RESULTS: Preoperative, intraoperative, and postoperative variables were equal in both groups. Postoperative bleeding in the 2nd hour was significantly lower in group 1 compared to group 2 (p=0.004). Bleeding 28-76 h postoperatively was also significantly lower in the first group (p=0.043). CONCLUSION: Our study suggests that contrary to the commonly held beliefs in our setup, the use of aspirin till the date of surgery does not increase the risk of postoperative bleeding after CABG. In contrast, our data show reductions in the bleeding incidence of those in whom aspirin was not withheld prior to surgery. Therefore we strongly recommend its continued use of aspirin until the date of surgery.

Analyzing the outcome of early versus prolonged extubation following cardiac surgery.

OBJECTIVES: This study considered the factors associated with prolonged ventilation and the effects of reduced extubation times on patient recovery, intensive care unit stay, and overall hospital stay. MATERIALS AND METHODS: A retrospective study was performed, including 86 consecutive patients who underwent cardiac surgery from August 2006 to January 2007. The patients were divided into two groups following intensive care unit admission: Group A, duration of intubation <4 h (n=34); Group B, duration of intubation >4 h (n=52). RESULTS: Two deaths occurred in 86 patients, and overall hospital mortality was 2.32%. Patients in Group A were younger (33.2+/-12 versus 45.8+/-13 years; p=0.001) and had better preoperative left ventricular ejection fraction (LVEF) (62.4+/-9.8 versus 44.6+/-9.4; p=0.003) than those in Group B. Moreover, Group A patients had a shorter intensive care unit length of stay (1.7+/-0.5 versus 2.2+/-0.8 days; p=0.006) and were discharged earlier than Group B patients (2.7+/-2.4 versus 4.01+/-3.96; p=0.014). CONCLUSIONS: Early extubation offers a substantial advantage in terms of accelerated recovery, shorter intensive care unit, and hospital stay, suggesting that efforts to reduce extubation times are cost-effective.

Assessment of risk factors for postoperative nausea and vomiting.

OBJECTIVE: To determine the risk factors for postoperative nausea and vomiting. STUDY DESIGN: Quasi-experimental study with prospective data collection. PLACE AND DURATION OF STUDY: The study was conducted at Dow Medical College University and Civil Hospital, Karachi from January to December 2004. PATIENTS AND METHODS: Data on patients' characteristic, anesthesia, surgery and postoperative nausea and vomiting was collected in operating theatre, postanesthesia care unit and wards. RESULTS: During postoperative 24 hours period, 60 out of a total of 200 patients experienced nausea and vomiting. The factors associated with an increased risk of Postoperative Nausea and Vomiting (PONV) were gender (female odds ratio 3), patients with previous history of nausea and vomiting or motion sickness (odds ratio 4), laparoscopic cholecystectomy (odds ratio 3.5) and eye surgery (odds ratio 3.9), all of these were statistically significant (p<0.05). No statistically significant difference was found between the other parameters. CONCLUSION: The incidence of PONV was found significantly higher in female gender, patients with previous history of nausea and vomiting or motion sickness, patient undergoing laparoscopic cholecystectomy and eye surgery.

Penetrating cardiac injury by a metallic fragment.

An adult male had a penetrating injury of the chest resulting in cardiac tamponade. The injury resulted as a consequence of a detached iron piece from an iron bar in a steel mill. Emergency sternotomy and percardiotomy revealed blood in the pericardial cavity and full thickness penetration of the right ventricle. The defect was repaired following the removal of the iron fragment. Postoperative recovery was uneventful.

The role of long-term antibiotics in the prevention of infection in postoperative cardiac surgeries.

OBJECTIVE: To compare the effect of long-term (7 days) versus short-term (2 days) postoperative antibiotics in preventing postoperative infective complications in patients who have undergone open-heart surgeries. DESIGN: Interventional, randomized controlled trial (RCT). PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, Dow University of Health Sciences, from February 2006 to July 2006. PATIENTS AND METHODS: Cardiac patients (n=42), operated for valvular disease (36%), coronary artery bypass grafting (50%), or septal repair (14%), were included in our study. Patients were prospectively randomized into two groups. Group A (n=21) patients received oral antibiotics for 7 days, whereas group B (n=21) patients were given the same for 2 days postoperative. Pre-operative and intra-operative variables were equal in both groups. Total leukocyte count and temperature were monitored daily until the patients were discharged. The chest and leg wounds were inspected daily for any signs of infection. Sputum and urine cultures were sent for selected patients in case of respiratory tract infection or urinary tract infection, respectively. Each patient was followed until the next routine visit in outpatient department. RESULTS: In group A, 3 patients (14%), developed infection postoperatively, whereas in group B, 13 patients (62%) (p =0.001) had to be started on oral or intravenous antibiotics as a result of developing either wound infection, a positive sputum culture, a positive urine culture or a localized infection elsewhere. Mean ward stay in group A was 4.8 +/- 4.5 days and in group B 6.5 +/- 4.1 days (p =0.011). CONCLUSION: In this series, there was a significantly higher frequency of infection and longer hospital stay in patients who received antibiotics for 2 days postoperatively as compared to those who received antibiotics for 7 days.