Operation theatre time utilization during emergency surgeries at a government institute of trauma in Karachi, Pakistan.

OBJECTIVE: To evaluate operation theatre time utilisation during emergency cases. METHODS: The prospective, observational study was conducted at the Shaheed Mohtarma Benazir Bhutto Institute of Trauma, Karachi, from January 17 to April 17, 2020, during which the three dedicated emergency operating rooms at the centre were monitored for time from transferring the patient to the operation theatre till the patient was shifted out after surgery. Data was analysed using SPSS 24. RESULTS: Of the total 1,287 surgeries performed, 625(48.56%) were included. Of them, 373(59.7%) patients were shifted to the operation theatre once it was ready, while 252(40.3%) were shifted in advance. There were 474(75.8%) male patients, and 151(24.1%) were females. The overall mean age was 32.7±17.4 years (range: ≤1 year to ≥47 years). Mean time of patient transfer to the operating room was 1:17±1:52 hours:minutes. Delay was recorded in 133(35. 6%) cases who were shifted from location when the operation theatre was available. It was caused in 64(17.15%) cases by surgical teams, another emergency surgery in the operating room 24(6.4%) and operating room cleaning 19(5%). The mean waiting time in the holding area was 1:25±1:21hours:minutes, and mean time from induction to surgical incision was 0:34±0:32 hours:minutes. Delays was caused by trainee surgeons in 79(12.64%) cases, and prolonged preoperative patient preparation in 99(15.84%). Mean turnover time was 0:48±0:42 hours:minutes. Delay was caused by post-operative unavailability of ambulance transportation 29(15%), and intensive care unit bed availability 14(7.2%). CONCLUSIONS: Time utilisation of emergency operation theatres can be maximised by improved overall coordination.

Prevalence, clinical presentation and treatment outcome of cryptosporidiosis in immunocompetent adult patients presenting with acute diarrhoea.

OBJECTIVE: To document the prevalence, clinical presentation and treatment outcome of cryptosporidiosis in immunocompetent adult patients presenting with acute diarrhoea. METHODS: This prospective cohort study was conducted at the Sindh Institute of Urology and Transplantation Karachi from February 1, till September 30, 2012. All immunocompetent adult patients who presented with acute diarrhoea to the gastroenterology clinic at SIUT were included. Data collection sheet was filled and stool studies sent. Modified acid fast stain of stool was performed for cryptosporidium. SPSS 20 was used for statistical analysis. RESULTS: There were 105 patients with acute diarrhoea. Fifty three (50.4%) were males. The mean age was 34 +/- 8.4 years. Of 105, 58 (55%) patients had cryptosporidium isolated in stool studies. Patients with cryptosporidiosis had statistically significant greater stool frequency per day (p < 0.001, OR = 12.7; CI [4.4-37.11), abdominal pain (p < 0.001, OR = 19.8 [6.1-64.11), vomiting (p < 0.001, OR = 7.3 [2.7-19.9]), low grade fever (p < 0.001, OR = 8.5 [3.5-20.8]), fatigue (p < 0.001, OR = 8.4 [3.2-21.6]) and dehydration and a shorter duration of illness with more watery diarrhoea. All 58 patients reported resolution of diarrhoea after 7 days of treatment with nitazoxanide. However, 40 (70.1%) patients reported recurrence of diarrhoea within 6 weeks of treatment. CONCLUSION: Our study demonstrates a high prevalence of cryptosporidiosis in immunocompetent adult patients. Nitazoxanide is the recommended antimicrobial drug for cryptosporidiosis.

Risk factors for carbapenem resistant bacteraemia and mortality due to gram negative bacteraemia in a developing country.

OBJECTIVE: To identify the risk factors for carbapenem resistant bacteraemia and mortality due to gram negative bacteraemia in a developing country. METHODS: A prospective cohort study was conducted at the Sindh Institute of Urology and Transplantation (SIUT) from June to October 2012. Hospitalized patients > 15 years of age with gram negative bacteraemia were included and followed for a period of 2 weeks for in hospital mortality. Data was collected and analyzed for 243 subjects. Multivariate analysis was used to determine the risk factors for carbapenem resistant bacteraemia and mortality due to gram negative bacteraemia. Crude and adjusted odds ratio and 95% CI are reported. RESULTS: A total of 729 out of 1535 (47.5%) cultures were positive for gram negative isolates. Out of 243 subjects, 117 (48%) had an MDR isolate. Having an MDR isolate on culture (AOR, 2.33; 95% CI, 1.35-4.0), having multiple positive cultures (AOR, 1.8; 95% CI, 0.94-3.4) and stay in ICU > 48 hours (AOR, 2.0; 95% CI, 1.12-3.78) were identified as significant risk factors for mortality due to gram negative organisms. Risk factors for carbapenem resistant bacteraemia were age > 50 years (AOR, 1.83; 95% CI, 1.0-3.5), septic shock on presentation (AOR 2.53; 95% CI, 1.03-6.2), ICU stay of > 72 hours (AOR 2.40; 95% CI, 1.14-5.0) and receiving immunosuppressant medications (AOR 2.23; 95% CI, 0.74-6.7). CONCLUSION: There is a high burden of MDR and carbapenem resistant gram negative bacteraemia, with a high mortality rate.

Frequency, clinical presentation and microbiological spectrum of candidemiain a tertiary care center in Karachi, Pakistan.

OBJECTIVE: To document the frequency, clinical presentation, outcome and spectrum of species in Candida blood stream infection. METHODS: A prospective, descriptive cohort study was conducted from June 1st till November 30th 2012 at the Sindh Institute of Urology and Transplantation in Karachi, Pakistan. All patients > or = 15 years of age from nephrology, urology, gastroenterology, oncology or intensive care units with candidemia were included. RESULTS: Of 2457 positive blood cultures, 145 (6%) were positive for Candida species in 121 patients. Seventy seven patients were included for further analysis as clinical data was available for these. The majority of patients had renal failure (89.6%) and 44% had femoral line. Non- albicans species were isolated in 70 (90.9%) patients; Candida parapsilosis in 28 (36.4%), C. lusitaniae in 23 (29.9%), C. tropicalis in 16 (20.8%), C. glabrata in 3 (3.9%) with only 7 (9.1%) with C. albicans. Mortality was 23.4% (18 patients). CONCLUSION: Frequency of candidemia and species distribution with predominantly non-albicans candida in our study is similar to that reported from other developing countries. Mortality is high. The majority of our patients had line related candidemia. Therefore prevention of line infection must be our top priority.

Low-cost thermotherapy for cutaneous leishmaniasis in Sindh, Pakistan.

OBJECTIVE: To study the efficacy of a low-cost heating pack device used for thermotherapy in the treatment of cutaneous leishmaniasis. METHODS: The study was conducted at the Department of Dermatology, Civil Hospital Sukkur, Pakistan, from April 20, 2012, to January 3, 2013. Thermotherapy with Hand-Held Exothermic Crystallisation Therapy for cutaneous leishmaniasis was performed on each lesion of the participating subjects at an average initial temperature of 51.6°C for 3 minutes daily for 7 days. Patients were followed regularly for 6 months after the therapy. SPSS 20 was used for statistical analysis. RESULTS: Even though all 27 patients completed 1 week of thermotherapy, only 23(85.2%) patients could be evaluated for full treatment response since 4(14.8%) were lost to complete follow-up. By the final 180-day evaluation, 19 (83%) patients had been cured. Applications were well tolerated with no side effects. CONCLUSION: The devise was a convenient, safe, non-toxic and effective treatment for cutaneous leishmaniasis at a fraction of the cost of standard antimonial treatment. Further studies are needed to certify its safety and efficacy as monotherapy for the condition.

Rhodococcus equi pneumonia in a live related renal transplant recipient.

Rhodococcus equi has emerged as a serious pathogen in immunocompromised patients, including solid organ transplant recipients. Primary pulmonary involvement is the most common presentation. However, this opportunistic pathogen is often not considered in the differential diagnosis of pneumonia in transplant recipients. Furthermore, in cultures, Rhodococcus can be misinterpreted by microbiologists in laboratories as a contaminant due to its morphology on gram staining if they have not been provided sufficient clinical information. We report a case of a young Asian male, 19 months post-live related renal transplantation who presented with a five-day history of productive cough, fever and weight loss. Chest radiography revealed bilateral basal infiltrates. Blood cultures and bronchoalveolar lavage yielded heavy pure growth of unbranched gram-positive rods which were identified as Rhodococcus equi (R. equi).

Chronic necrotizing pulmonary aspergillosis in a renal transplant recipient.

Chronic necrotizing pulmonary aspergillosis is a chronic semi invasive pulmonary disease. It is an uncommon disease and has never been reported in transplant recipients. We report a case of chronic necrotizing pulmonary aspergillosis in a renal transplant recipient.

Clinical Characteristics and Outcome of Patients With Severe COVID-19 Pneumonia at a Public Sector Hospital in Karachi, Pakistan.

INTRODUCTION: In Pakistan, the first case of COVID-19 was reported in February of 2020, cases peaked in June, and by January 2021, approximately 500,000 confirmed cases and over 10,000 deaths have been reported. There is a lack of data in Pakistan of the demographics, clinical characteristics, and outcome of patients with COVID-19 pneumonia, particularly those with severe illness, which we aim to assess. METHODS: This is a single-centered, observational study conducted at the COVID unit of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma in Karachi, Pakistan. A manual medical record review of patients admitted from April 24, 2020 to August 24, 2020 was conducted, and all patients with polymerase chain reaction (PCR) positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) with moderate, severe, and critical COVID-19 pneumonia were included. RESULTS: Of 299 patients, the median age was 60 years (50-65). Males accounted for 221 (73.9%). Most common symptoms were shortness of breath seen in 270 (90.3%) and fever in 225 (75.3%) patients. Diabetes mellitus (51.2%) and hypertension (50.3%) were the predominant co-morbidities. COVID disease was categorized on admission as moderate in 68 (22.7%), severe in 151 (50.5%), and critical in 80 (26.8%) patients. Survival analysis was done in 252 patients, all of whom received steroids, while tocilizumab was administered to 111 (44%) patients. Hundred (39.7%) patients received non-invasive ventilation (NIV), while 57 (22.6%) were placed on mechanical ventilation. Overall, 95 (37.7%) patients died. Factors associated with mortality included older age with those above 60 years more likely to die (odds ratio [OR]: 1.925; 95% CI: 1.148-3.228; pvalue: 0.009), presence of co-morbidities (OR 1.843; 95% CI: 0.983-3.456; p value: 0.070), development of cytokine release syndrome (CRS) (73 [56.2%] vs 57 [43.8%], p value: <0.001), acute kidney injury (31 [81.6%] vs 7 [18.4%], p value: <0.001), cardiac complications (12 [75%] vs 4 [25%], p value: 0.002), and sepsis (29 [87.9%] vs 4 [12.1%], p value: <0.001). Non-survivors were more likely to develop acute respiratory distress syndrome (ARDS), having been placed on NIV and mechanical ventilation. Laboratory parameters at final outcome found that in non-survivors, median total leukocyte count, C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) were higher, while absolute lymphocyte count and platelet counts were lower which were found to be statistically significant compared to survivors. CONCLUSION: In this study of patients with severe COVID-19 pneumonia at a public sector hospital in Karachi, Pakistan, most were males, and the average age was 60 years. Mortality was high, and associated factors included older age, presence of comorbid conditions, and the development of ARDS, CRS, and sepsis.

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak.

BACKGROUND: In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care. METHODS: In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV. FINDINGS: Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions. INTERPRETATION: This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies. FUNDING: None.

Self-reported practices of hand hygiene among the trainees of a teaching hospital in a resource limited country.

OBJECTIVE: To determine the compliance of hand hygiene among the trainee physicians of a tertiary care teaching hospital; and to identify physicians' opinion regarding various obstacles in adhering to the hand hygiene principles. METHODS: Cross-sectional survey was conducted among the Interns (House Officers) and Post Graduate trainee physicians of a tertiary care teaching hospital in a resource limited country. Subjects were consented and selected through non probability convenient sampling. A self-administered questionnaire, based on the hand hygiene guidelines laid down by the World Health Organization (WHO) was used. RESULTS: A total of 211 questionnaires were completed. Only 4.7% of the physicians reported to decontaminate their hands before having direct contact with their patients. Only 17% claimed to be aware of the WHO recommendations on hand hygiene. Majority of subjects considered "lack of sinks, soap, water and disposable towel" as a major barrier towards hand hygiene adherence. Overall compliance of hand hygiene was found to be 38.8% but it widely varied as a function of patient care activity. CONCLUSION: Hand hygiene practices among trainee physicians were not in line with WHO recommendations. To make a difference, interventions taken to improve awareness alone, won't be sufficient; they have to be supported with improving facilities for hand hygiene.

Coccidioidomycosis and pregnancy: a review.

Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States, northwestern Mexico, and parts of Central and South America. CM has been recognized as a complicating factor in pregnancy since at least the 1940s, and seems to be a relatively uncommon infection during pregnancy. The disease presentation during pregnancy includes a wide clinical spectrum that ranges from mild influenza-like illness and pneumonia, especially in the first two trimesters of pregnancy. The third trimester of pregnancy is a time of high risk for dissemination. Immunologic and hormonal changes during pregnancy and the postpartum period may account for any increased frequency and severity of disease observed during pregnancy. Early diagnosis and appropriate aggressive therapeutic intervention with careful monitoring usually result in good outcome.

Perceptions of gender equality, work environment, support and social issues for women doctors at a university hospital in Riyadh, Kingdom of Saudi Arabia.

The Kingdom of Saudi Arabia (KSA) is an Islamic monarchy and was established in 1932. Saudi women first entered the medical field in 1975 and the country has since seen a steady increase in women pursuing medicine. However, there is limited data on gender related issues for women doctors practicing in Saudi Arabia. Therefore, our study objective was to assess the perception amongst peers regarding gender equality and social issues faced by women doctors in Saudi Arabia. An online anonymous cross-sectional survey was administered in English to doctors at King Khalid Hospital, affiliated to King Saud University, in Riyadh, between April and May of 2016. Of 1015 doctors, 304 (30%) participated, of which 129 (42.4%) were females and 231 (76%) were Saudi nationals. The average age was 32.4 years (±SD: 8.7). The majority opined that there was no gender discrimination in salaries (73.7% p-value = 0.4), hospital benefits (62.2% p-value = 0.06) or entry into any field of Medicine/Pediatrics (68.4% p-value = 0.207). However, only a minority believed that there was no gender discrimination for entry into surgery (37.3% p-value = .091). A higher proportion of male doctors agreed that promotion opportunities are equal (66.3% vs 45.7%, p-value = 0.002). However, of 54 consultants, only 18 (33.3%) were women. Over half of the women (52.3%) reported that they never wear the face veil. Only a minority of male and female doctors (12.2%) believed women doctors should wear the veil since they examine male patients. Fewer respondents believed that female doctors face harassment from male doctors (14.5%) whereas 30.7% believed female doctors face harassment from male patients. More females, than males, agreed with the statement that female doctors are as committed to their careers as are males (92.2% vs 67.4%, p-value<0.0001). Of 304 participants, 210 (69.1%) said that they would still choose to become a doctor with approximately equal proportions between males and females (68% vs 70.5%, p-value = 0.79). In conclusion, our survey of male and female doctors at a government university hospital in Saudi Arabia revealed that the majority believed there was gender equality amongst doctors in terms of salaries, benefits, opportunities for promotion and entry into any field of medicine or pediatrics, but not surgery. However, there were significantly fewer women at consultant positions, a deficiency that needs to be addressed.

Seroprevalence of HIV, HBV and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan.

In Pakistan, male sex workers are predominantly transvestites and transsexuals known as Hijras. In 1998 in Karachi, Pakistan, we studied the seroprevalence of HIV, HBsAg and syphilis and associated risk factors in Hijras. Study subjects were verbally administered a structured questionnaire that determined risk behaviours for sexually transmitted and blood-borne diseases and knowledge of AIDS/STDs. After pre-test counselling, verbal consent was taken for serological testing. The results were provided on a one-on-one post-test counselling session. Three hundred male transvestites were approached; all agreed to answer the questionnaire, 208 consented to blood testing. Of 300, 81% acknowledged commercial sex with men. Of 208, prevalence of syphilis was 37%; HBsAg 3.4%; HIV 0%. The prevalence of HIV and hepatitis B virus (HBV) is low in transvestite sex workers but that of syphilis is high. Intervention programmes implemented at this stage can have an impact on HIV and STD prevention (Int J STD AIDS 1990;10:300-4).

Diversity of methicillin-resistant Staphylococcus aureus CC22-MRSA-IV from Saudi Arabia and the Gulf region.

OBJECTIVES: CC22-MRSA-IV, UK-EMRSA-15/Barnim EMRSA, is a common and pandemic strain of methicillin-resistant Staphylococcus aureus (MRSA) that has been found mainly in Western Europe, but also in other parts of the world including some Gulf countries. One suspected case of an infection with this strain in a patient who was admitted to the surgical unit in Riyadh, Kingdom of Saudi Arabia (KSA) was investigated in order to check whether this strain has reached KSA. METHODS: Besides the index isolate, 46 additional isolates of CC22-MRSA-IV from patients from KSA, Abu Dhabi, Kuwait, and Germany (patients with a history of travel in the Middle East), were characterized by microarray hybridization. RESULTS: The study revealed a regional presence of as many as six distinct 'strains' of CC22-MRSA-IV that could be distinguished based on carriage of SCCmec IV subtypes and virulence factors. No true UK-EMRSA-15/Barnim EMRSA was identified in Riyadh; all suspected isolates from Riyadh were assigned to other, albeit related strains. However, this strain was identified in Abu Dhabi and Kuwait. CONCLUSIONS: CC22-MRSA-IV from KSA could be linked to other epidemic strains from the Middle East and possibly India, rather than to the Western European UK-EMRSA-15/Barnim EMRSA. High-resolution typing methods, including SCCmec subtyping, might help to differentiate related epidemic strains and to monitor routes of transmission.

Four years of experience with antiretroviral therapy in adult patients in Karachi, Sindh, Pakistan.

The Sindh AIDS Control Program (SACP) in Pakistan began dispensing combination antiretroviral therapy (ART) in May 2006 in Karachi. This study aimed to assess the management and outcomes of ART-treated patients. Data were extracted from medical records of adult patients registered with the SACP who received ART between May 2006 and May 2010. In total, 300 patients received ART, of whom 77.7% were men. The median CD4 cell count at the time of joining the SACP was 130 cells/mm(3). ART was nevirapine-based in 69.1% of cases and was correctly prescribed in 97.3%. Of 257 patients who received ≥1 month of ART, >90% were regular with their medications and appointments. Of the 300 patients, 70 (23.3%) had HIV-related deaths and 4 (1.3%) had non-HIV-related deaths, whereas 32 (10.7%) transferred out and 16 (5.3%) stopped attending the clinic and could not be traced. Estimated survival in the first 6 months stratified by initial CD4 lymphocyte count ≥50 cells/mm(3) and <50 cells/mm(3) was 85.8% (95% CI 80.8-90.0%) and 52.2% (95% CI 40.9-63.1%), respectively. Viral suppression was achieved in 95.4% of those who survived beyond 3 months of starting ART. ART can be managed adequately with excellent patient adherence and satisfactory clinical outcomes in a resource-limited setting.