Pancreatic masses in children: a single-center experience over two decades.

Pancreatic masses are extremely rare in pediatric patients, with limited data available. This lack of data makes the diagnosis and management of these tumors in children extremely challenging. Therefore, we aimed to describe the presentations, clinical course, and outcomes of children with pancreatic tumors at our center. A retrospective analysis was performed of all pediatric patients diagnosed with pancreatic masses between 2003 and 2022 in an academic freestanding children's hospital. Data including demographics, clinical presentation, workup, management, and subsequent morbidity and mortality were collected and aggregated. Furthermore, we reviewed cases of pancreatic tumor resections in the National Surgical Quality Improvement Program - Pediatric (NSQIP-P) database to identify common adverse outcomes and measures for quality improvement. In total, 17 patients were identified at our institution. Diagnoses included solid pseudopapillary (n = 9), gastrinoma (n = 1), rhabdomyosarcoma (n = 2), pancreatoblastoma (n = 2), and insulinoma (n = 1). Two patients did not have a histopathologic diagnosis and were excluded from subsequent analysis. Overall, 12 patients underwent surgical intervention, with the most common procedures being pancreaticoduodenectomy and distal pancreatectomy, and all 12 were known to be alive at last contact. There were 3 deaths, all due to complications related to metastatic disease. Furthermore, 30-day postoperative outcomes in the NSQIP-P dataset for pancreatic surgeries in pediatric patients are excellent, with negligible morbidity and no mortalities after the index surgery. CONCLUSIONS: Children with pancreatic tumors amenable to surgical resection appear to have adequate long-term survival. Short-term outcomes at diagnosis are excellent and mainly appear to be influenced by the presence of metastatic disease at initial presentation. WHAT IS KNOWN: • Pancreatic masses are a rare entity in children with limited data on their presentation, management and surgical outcomes. • Solid Pseudopapillary tumors are one of the most common pancreatic tumors in children with a fair prognosis after surgical intervention. WHAT IS NEW: • Surgical management of pediatric patients with pancreatic tumors is safe and effective in patients who do not have aggressive tumor types or metastatic disease. • Our case series provides a notable cohort of these pancreatic tumors with insight into the presentation, management and outcomes of five of these tumor types.

Much room for change: access to surgical care for stateless individuals in Pakistan.

BACKGROUND: As developing countries take steps towards providing universal essential surgery, ensuring the equitable distribution of such care for underrepresented populations is a vital function of the global surgery community. Unfortunately, in the context of the global "stateless", there remains much room for improvement. KEY ISSUES: Inherent structural deficiencies, such as lack of adequate population data on stateless communities, absent health coverage policies for stateless individuals, and minimal patient-reported qualitative data on barriers to surgical service delivery prevent stateless individuals from receiving the care they require - even when healthcare infrastructure to provide such care exists. The authors therefore propose more research and targeted interventions to address the systemic issues that prevent stateless individuals from accessing surgical care. CONCLUSION: It is essential to address the aforementioned barriers in order to improve stateless populations' access to surgical care. Rigorous empirical and qualitative research provides an important avenue through which these structural issues may be addressed.

Factors predicting mortality among patients with COVID-19 associated hospital acquired pneumonia: insights from a tertiary care center.

Hospital acquired pneumonia (HAP) is a severe and dangerous complication in patients admitted with COVID-19, causing significant morbidity and mortality globally. However, the early detection and subsequent management of high-risk cases may prevent disease progression and improve clinical outcomes. This study was undertaken in order to identify predictors of mortality in COVID-19 associated HAP. A retrospective study was performed on all patients who were admitted to a tertiary care center with COVID-19 associated HAP from July 2020 till November 2020. Data was collected on relevant demographic, clinical and laboratory parameters to determine their association with in-hospital mortality; 1574 files were reviewed, out of which 162 were included in the final study. The mean age of subjects was 59.4±13.8 and a majority were male (78.4%). There were 71 (48.3%) mortalities in the study sample. Klebsiella pneumoniae (31.5%) and Pseudomonas aeruginosa (30.2%) were the most common organisms overall. Clinically significant growth of Aspergillus sp. was observed in 41 (29.0%) of patients. On univariate analysis, several factors were found to be associated with mortality, including male gender (p=0.04), D-dimers >1.3 mg/L (p<0.001), ferritin >1000 µg/mL (p<0.001), LDH >500I.U/mL (p<0.001) and procalcitonin >2.0 µg/mL (p<0.001). On multivariate analysis, ferritin >1000ng/mL, initial site of care in Special Care Units or Intensive Care Units, developing respiratory failure and developing acute kidney injury were factors independently associated with mortality in our patient sample. These results indicate that serum ferritin levels may be a potentially useful biomarker in the management of COVID-19 associated HAP.

Comparative Trends in Ischemic Heart Disease Admissions, Presentation and Outcomes Due to the COVID-19 Pandemic: First Insights From a Tertiary Medical Center in Pakistan.

Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p<0.001), month of admission (p<0.001), proportions ACS (p<0.001), non-ST-elevation-myocardial-infarction (NSTEMI; p<0.001), unstable angina (p=0.025) and medical management (p=0.002) showed significant differences between the two groups, with a sharp decline in the during-COVID group. Monthly trend analysis of ACS patients showed the most significant differences in admissions (p=0.001), geographic region (intra-district vs intracity vs outside city) (p<0.001), time of admission (p=0.038), NSTEMI (p=0.002) and medical management (p=0.001). Conclusion These data showcase stark declines in ACS admissions, diagnostic procedures (angiography) and revascularization interventions (angioplasty and coronary artery bypass graft surgery, CABG) in a developing country where resources and research are already inadequate. This study paves the way for further investigations downstream on the short- and long-term consequences of untreated IHD and reluctance in health-seeking behaviour.