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.

Utility of biomarkers in predicting complications and in-hospital mortality in patients with COVID-19.

Objectives: To determine the association between the laboratory biomarkers (C-reactive protein (CRP), Ferritin, lactate dehydrogenase (LDH), Procalcitonin, and D-dimer) with complications and in-hospital mortality in COVID-19 patients. Methods: This single-center, cross-sectional study was conducted at the Department of Emergency Medicine of Aga Khan University Hospital from April 01, 2020, to July 31, 2020. Descriptive statistics were presented as Mean±SD and Median along with Range. The frequencies and percentages were calculated for all categorical variables. Univariate and multivariate analysis was carried out to evaluate the significant association between the laboratory biomarkers and in-hospital mortality. Results: A total of 310 adult COVID positive patients were included. The most common complication was acute respiratory distress syndrome (ARDS) (37.1%), followed by myocardial injury (MI) (10.7%), deep vein thrombosis (DVT) (0.6%), and pulmonary embolism (PE) (0.3%). In-hospital mortality was 15.2%. In univariate analysis, it was observed that increased values of all biomarkers were significantly associated with the prediction of in-hospital mortality using binary logistic regression analysis (OR > 1.0, P <0.05). In multivariate analysis, increased levels of LDH and D-dimer at admission were significantly associated with increased odds of mortality (P <0.05). Conclusion: Serum CRP, ferritin, Procalcitonin, LDH, and D-dimer levels at the time of admission can predict complications like ARDS and MI and also predict mortality in COVID-19 infection. Serum LDH and D-dimer are the best amongst them for predicting mortality.

Bedside index (BISAP) v/s Ranson scores in predicting mortality and severity in patients with acute pancreatitis.

OBJECTIVE: To determine the diagnostic accuracy of the bedside index for severity in acute pancreatitis in comparison with Ranson scores in predicting mortalities and severities in patients with acute pancreatitis. METHODS: The cross-sectional study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from July 1, 2017, to January 1, 2018, and comprised patients who presented with acute pancreatitis. The bedside index for severity in acute pancreatitis score was applied in the emergency department and the patients were followed up in ward/intensive care unit where Ranson scores were calculated within the following 48 hours. Both the scores were calculated and compared for the prediction of severity and mortality for each patient. Data was analysed using SPSS 20. RESULTS: Of the 136 patients, 88(64.7%) were males and 48(35.3%) were females. The overall mean age was 42.04±16.42 years (16-75 years), On the basis of two scores, mild and moderate acute pancreatitis was diagnosed in 123(90.4%) and 119(87.5%) patients respectively, while severe condition was diagnosed in 13(9.6%) and 17(12.5%) patients respectively. The bedside index had specificity 94.62% compared to 91.54% for Ranson score; sensitivity 100% vs 100%; negative predictive value 100% vs 100%; positive predictive value 46.15% vs 35.29%; and diagnostic accuracy 94.85% vs 91.91%. CONCLUSIONS: The bedside index for severity in acute pancreatitis and Ranson score were both found to be reliable tools in predicting mortalities and severities in patients with acute pancreatitis.

Clinical audit on indications and technique of male urethral catheterization in emergency department of a tertiary care hospital.

Urethral catheterization (UC) is a common procedure done in the Emergency Department of a hospital. The main indications for a UC are relieving acute urinary retention and bladder outlet obstruction. This cross-sectional audit was carried out between July 2019 to February 2020, in the Emergency Department (ED). All male patients aged 18 years and above, in whom UC was performed, were included in the audit. A total of 81 male patients were surveyed. Although, sterilized technique was maintained by using sterile gloves and pyodine but hand hygiene (sterilization or hand wash) was not performed before the procedure 80% of times. CDC hand hygiene guidelines were distributed to promote hand hygiene. What do we already know about this topic ? The Lippincott guidelines are considered gold standard which includes hand hygiene as an important element of urinary catheterization UC. The CDC Center of Disease Control CDC promotes the use of mandatory gloves and generous hand sanitizing before procedures. How does your research contribute to the field For continuous improvement and patient focused practice, we must audit the technique of nursing staff, doctors and health care assistants who are involved in insertion and ordering of catheters to provide quality health care and avoid unnecessary catheterization [1]. The aim of this study was to audit the appropriateness of usage of urinary catheters by the healthcare staff and, their technique of insertion and indications for urinary catheterization. What are your research's implications towards theory, practice, or policy? Hand hygiene is an important element of patient care. If done properly it can prevent several hospital-acquired infections. Heathcare facilities must audit their staff on regular basis and provide refreshers and promote the use of proper hand hygiene before urinary catheterization.

Randomised controlled trial to assess the effectiveness of apnoeic oxygenation in adults using low-flow or high-flow nasal cannula with head side elevation versus usual care to prevent desaturation during endotracheal intubation in the emergency department (ApOxED): study protocol.

INTRODUCTION: Apnoeic oxygenation is a process of delivering continuous oxygen through nasal cannula during direct laryngoscopy. The oxygen that is delivered through these nasal cannulas is either low flow or high flow. Although the effectiveness of apnoeic oxygenation has been shown through systematic reviews and randomised controlled trials, a comparison of high-flow versus low-flow oxygen delivery has not been tested through a superiority study design. In this study we propose to assess the effectiveness of giving low-flow oxygen with head side elevation versus high-flow oxygen with head side elevation against the usual practice of care in which no oxygen is provided during direct laryngoscopy. METHODS AND ANALYSIS: This will be a three-arm study instituting a block randomisation technique with a sample size of 46 in each arm (see table 1). Due to the nature of the intervention, no blinding will be introduced. The primary outcomes will be lowest non-invasive oxygen saturation measurement during direct laryngoscopy and during the 2 min after the placement of the tube and the first pass success rate. The intervention constitutes head side elevation up to 30° for improving glottis visualisation together with low-flow or high-flow oxygen delivery through nasal cannula to increase safe apnoea time for participants undergoing endotracheal intubation. Primary analysis will be intention to treat. ETHICS AND DISSEMINATION: The study is approved by the Ethical Review Committee of Aga Khan University Hospital (2019-0726-2463). The project is an institution University Research Committee grant recipient 192 002ER-PK. The results of the study will be disseminated among participants, patient communities and healthcare professionals in the institution through seminars, presentations and emails. Further, the findings will be published in a highly accessed peer-reviewed medical journal and will be presented at both national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04242537).