Frequency of neuro-imaging in the emergency room in patients with vertigo: A cross-sectional study at a tertiary care hospital in Karachi, Pakistan.

Objective: To determine the frequency of neuro-imaging and the prevalence of positive findings in patients with vertigo visiting an emergency room of a low-middle-income-country, Pakistan. Methods: This is a retrospective cross-sectional study conducted in the emergency room of the Aga Khan University Hospital, a 550 bedded tertiary care teaching facility located in Karachi, Pakistan. The frequency of neuro-imaging in patients visiting emergency room with vertigo during 20 years (2000-2020), their findings and disposition was calculated in percentages. A cost-analysis was performed in Pakistani Rupees & US Dollars to estimate the financial burden. Results: During the emergency room visits for vertigo, neuro-imaging (CT scans, MRIs, or both) was conducted for 159 patients, accounting for 70.98% of the cases. Out of these, 64 individuals (40.25%) received a positive diagnosis, which included acute infarcts, hemorrhages, metastases, space-occupying lesions, and meningeal enhancements. Interestingly, among those with negative findings, the 98 patients faced significantly higher costs, amounting to Rs.4,108,000 ($22,449), in contrast to the positive cases, which incurred Rs.2,496,600 ($13,642). Conclusion: The frequency of obtaining neuro-imaging tests in patients with vertigo were significantly high in our study. In addition, there was a significant financial burden associated with neuro-imaging especially for our low-middle-income country.

Knowledge, attitudes, practices and perceived barriers of emergency health care providers regarding sepsis and septic shock in a tertiary care centre: A cross-sectional study.

This study aimed to assess knowledge, attitudes, practices, and perceived barriers of emergency healthcare providers regarding the management of sepsis and septic shock. This cross-sectional study was conducted in the Emergency Department of Aga Khan University Hospital, Karachi, Pakistan from August to October 2017. A total of 53 healthcare providers participated in the study. Overall, 42(79%) of the participants demonstrated correct knowledge of the sepsis bundle. The most common barrier reported in the compliance of the sepsis bundle was a shortage of staff (62%), followed by delayed presentation of patients (58%) and overcrowding (42%). Furthermore, better staffing was perceived by the participants (60%) to improve the care of septic patients, followed by sepsis awareness sessions (23%) and reduction in ED crowding (11%). Staff shortage, delayed presentation of patients, and ED overcrowding were considered the most common barriers in the management of sepsis in this setting.

Association between long COVID and vaccination: A 12-month follow-up study in a low- to middle-income country.

OBJECTIVE: There is a lack of estimates regarding the at-risk population associated with long COVID in Pakistan due to the absence of prospective longitudinal studies. This study aimed to determine the prevalence of long COVID and its association with disease severity and vaccination status of the patient. DESIGN AND DATA SOURCES: This prospective cohort study was conducted at the Aga Khan University Hospital and recruited patients aged > 18 years who were admitted between February 1 and June 7, 2021. During this time, 901 individuals were admitted, after excluding patients with missing data, a total of 481 confirmed cases were enrolled. RESULTS: The mean age of the study population was 56.9±14.3 years. Among patients with known vaccination status (n = 474), 19%(n = 90) and 19.2%(n = 91) were fully and partially vaccinated, respectively. Severe/critical disease was present in 64%(n = 312). The mortality rate following discharge was 4.58%(n = 22). Around 18.9%(n = 91) of the population required readmission to the hospital, with respiratory failure (31.8%, n = 29) as the leading cause. Long COVID symptoms were present in 29.9%(n = 144), and these symptoms were more prevalent in the severe/critical (35.5%, n = 111) and unvaccinated (37.9%, n = 105) cohort. The most prominent symptoms were fatigue (26.2%, n = 126) and shortness of breath (24.1%, n = 116), followed by cough (15.2%, n = 73). Vaccinated as compared to unvaccinated patients had lower readmissions (13.8% vs. 21.51%) and post-COVID pulmonary complications (15.4% vs. 24.2%). On multivariable analysis, after adjusting for age, gender, co-morbidity, and disease severity, lack of vaccination was found to be an independent predictor of long COVID with an Odds ratio of 2.42(95% CI 1.52-3.84). Fully and partially vaccinated patients had 62% and 56% reduced risk of developing long COVID respectively. CONCLUSIONS: This study reports that the patients continued to have debilitating symptoms related to long COVID, one year after discharge, and most of its effects were observed in patients with severe/critical disease and unvaccinated patients.

Effectiveness of High-Fidelity Simulation in Training Emergency Medicine Physicians in Point of Care Ultrasonography in Pakistan: A Quasi-Experimental Study.

Background Point-of-care ultrasound (PoCUS) is frequently utilized in emergency medicine (EM), with an extended-focused assessment with sonography in trauma (e-FAST) being the most widely used PoCUS modality. This modality is not only time- and cost-efficient, but it is highly accurate in the diagnosis and management of surgical patients in the emergency department, as well as being highly predictive of patient outcomes. Targeted training is essential to ensure a learner's confidence in image acquisition, interpretation, and translation of knowledge to making clinical decisions. High-fidelity simulation offers a uniquely safe and "mistake-forgiving" environment to teach and train medical professionals. The present study evaluated the effectiveness of a high-fidelity simulator to train EM physicians in e-FAST at a tertiary care teaching hospital in a lower-middle-income country. Methods This quasi-experimental study was performed at a state-of-the-art simulation center of a multidisciplinary university hospital in Karachi, Pakistan. Subjects were included if they were EM physicians who volunteered to participate and were available for the entire training and testing period. The educational intervention included lectures and hands-on practice on a high-fidelity simulator (SonoSim, Santa Monica, CA). Knowledge and image interpretation on e-FAST were evaluated using a questionnaire, administered before and after the training course. Each participant's ability to acquire and interpret satisfactory images was assessed by experienced EM physicians and recorded. Participants were also administered a needs assessment survey and a course evaluation. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). All the tests were two-sided, and p-values ≤0.05 were considered significant. Baseline characteristics and outcome variables were recorded and compared by Wilcoxon signed-rank tests. Results A total of 31 EM physicians, 12 (38.7%) men and 19 (61.3%) women, were enrolled in the study, with 24 (77.3%) having one to three years of EM experience. Mean and percentage group performance improved from 6 and 40% before the intervention to 14.5 and 96.6% after the intervention (Z=4.867, p≤0.05). Most improvement in image acquisition on high-fidelity simulation was observed in the upper right quadrant of the suprapubic window (29/31; 93.5%), followed by the upper left quadrant (27/31; 87%) and the subxiphoid window (21/31; 67%). All 31 participants reported improvements in comfort and confidence level with PoCUS after attending the workshop. Conclusions EM physicians who attended a brief workshop incorporating simulation demonstrated improvements in knowledge and image acquisition skills in all domains tested. High-fidelity simulation training is an effective modality for training EM physicians in e-FAST.

Understanding perceptions and factors involved in do not resuscitate (DNR) decision making in the emergency department of a low-resource country: a mixed-methods study protocol.

INTRODUCTION: Do not resuscitate (DNR) decision making is an integral component of emergency medicine practice. There is a paucity of data, protocols and guidelines regarding the perceptions and barriers that are involved in the interactions among healthcare professionals, patients and their caregivers regarding DNR decision making. The aim of this study is, therefore, to explore the perceptions and factors influencing DNR decision making in the emergency department and to evaluate the use of a context-based protocol for DNR decision making. METHODS AND ANALYSIS: This will be a sequential mixed method study beginning with qualitative research involving in-depth interviews (IDIs) with patient family members and focus group discussion with healthcare professionals. The consensual qualitative approach will be used to perform a thematic analysis to the point of saturation. The expected outcome will be to identify key themes that suggest perceptions and factors involved in DNR decision making. After piloting, the derived protocol will then be used with a different group of individuals (150 healthcare professionals) who meet the eligibility criteria in a quantitative cross-sectional study with universal sampling. Data will be analysed using NVIVO in the qualitative phase and SPSS V.19 in the quantitative phase. The study findings will support the development of a standardised protocol for DNR decision making for healthcare professionals in the emergency department. ETHICS AND DISSEMINATION: The proposal was reviewed by the ethics review committee (ERC) of the institution (ERC # 2020-1551-7193). The project is an institution SEED grant recipient PF139/0719. The results will be disseminated among participants, patient communities and healthcare professionals in the institution through seminars, presentations, brochures and emails. The findings will be published in a highly accessed peer-reviewed medical journal and will be presented at international conferences.