Validation of Difficult Airway Physiological Score (DAPS) in Critically Ill Adults Undergoing Endotracheal Intubation in the Emergency Department.

Background: Critically ill patients have increased risk of cardiovascular collapse following endotracheal intubation due to physiological instability. This study aims to validate the Difficult Airway Physiological Score (DAPS) in adults to predict the risk of serious outcomes in the emergency department of a tertiary care private hospital. Methods: This is a cohort study conducted in the emergency department (ED) from 2021 to 2022. Difficult Airway Physiological Score (DAPS) was derived from a sample of 1021 patients through a retrospective study. The variables in the score were age, gender, time of intubation, vitals and vomiting at presentation, pH <7.3, fever, physician's anticipation for patient decline, and agitation. The model performance was assessed prospectively on a separate dataset (n = 326) using train-test split method. Postintubation desaturation, hypotension, cardiac arrest, and mortality postintubation were the serious outcomes. ROC analysis, sensitivity, specificity, PPV, and NPV were used to assess score validity. Results: Our study includes 326 patients, of which 123 (37.7%) were males and 203 (62.2%) were females. The sample was divided into high-risk (DAPS ≥10) group, n = 194 with mean age of 52 (SD = ±18) years, and low-risk (DAPS <10) group, n = 132 with mean age of 47.7 (SD = ±17.4) years. The shock index ≥0.9 was in 128 (66%), while it was <0.9 in low-risk n = 111 (84%), p value <0.001. Similarly, pH <7.3 was seen in 70 (36.1%) in high-risk group compared to 4 (3%) in low-risk group, p value <0.001. Cardiac arrest was observed in 56 (17.2%) patients, of which 45 (23.2%) were in high-risk and 11 (8.3%) in low-risk groups (p < 0.001). Hypotension was the primary outcome in the high-risk group 100 (51.5%) versus 32 (24.2%) in low-risk group (p < 0.001). The DAPS of 10 had an area under the curve of 0.865 (0.71-0.84). The sensitivity of DAPS was 78.5%, specificity 77.9%, and accuracy 78.2%. Conclusion: The score can accurately predict serious outcomes in critically ill adult patients with physiologically difficult airway demonstrating good sensitivity and specificity.

Thirty-year trends of triple burden of disease in the adult population of Pakistan.

BACKGROUND: The triple burden of disease, i.e. communicable diseases, non-communicable diseases and injuries, has significantly affected the healthcare system of Pakistan during the last three decades. Therefore, this study aims to determine and analyse the 30-year disease burden trends through prevalence, death rates and percentages. METHODS: The data for the last three decades, i.e. 1990 to 2019, was extracted from the Global Burden of Disease for Pakistan. Percentage change in prevalence and deaths over 30 years was calculated. Poisson regression analysis was performed to evaluate the triple disease burden trends and the incidence rate ratio. RESULTS: A relative decrease of 23.4% was noted in the prevalence rate of communicable diseases except for human immunodeficiency virus and dengue fever. A relative increase of 1.4% was noted in the prevalence rate of non-communicable diseases. A relative increase of 56.1% was recorded in the prevalence rate of injuries. The prevalence rate ratios of communicable diseases significantly decreased to 0.9796 [95% CI: 0.9887-0.9905], but the prevalence rate of injury increased to 1.0094 [95% CI: 1.0073-1.01145], respectively. CONCLUSION: Pakistan must take the next steps and develop strategies to decrease this burden and mortality rates in the population to create better outcomes and therefore help the healthcare system overall.

Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department.

BACKGROUND: Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. METHOD: This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. RESULTS: The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. CONCLUSION: DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

A Case for Global Surgery in Pakistan: Implementation Through Multi-Disciplinary Engagement.

The increasing disparity in healthcare access in Pakistan requires immediate intervention in the form of informed policy and appropriate implementation of such a policy. The implementation of a global surgery framework in Pakistan has the potential to improve healthcare access and parity in rural areas. Benefitting from the lessons learned through previous attempts at implementing centrally planned health programmes, This paper makes the case for a decentralised approach in facilitating the implementation of a Global Surgery framework in Pakistan. The Critical Creative Innovative Thinking (CCIT) forum, established at the Aga Khan University (AKU), Karachi, has an important role to play in this regard. The CCIT forum has demonstrated ability in developing and facilitating multi - disciplinary engagement around topics of biomedicine and healthcare, and in growing such engagements to their commercial value. Hence, the CCIT forum has immense potential in creating a highfunctioning ecosystem around Global Surgery, thereby formulating a dynamic implementation plan - outside of conventional, centrally implemented public policy frameworks.

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.