A scoping review of the outcome reporting following surgery for chronic osteomyelitis of the lower limb.

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was 'recurrence of osteomyelitis' (62; 12%). The single-most patient-reported outcome measure was 'pain'. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies.

Major adverse cardiovascular events in patients undergoing percutaneous coronary intervention or coronary artery bypass graft with underlying chronic kidney disease.

OBJECTIVE: To assess early and late outcome in severe chronic kidney disease patients undergoing revascularisation. METHODS: The retrospective ambi-directional cohort study was conducted at Tabba Heart Institute, Karachi, and comprised data from May, 2012, to July,2016, related to severe chronic kidney disease patients with creatinine clearance <30ml/min or end-stage renal disease on haemodialysis who had undergone coronary artery bypass graft / percutaneous coronary intervention. Early outcome was in-hospital major adverse cardiac event, like mortality, stroke and new haemodialysis. Late outcome was major adverse cardiac event, like mortality, stroke, re infarction and re-revascularisation. Data was analysed using Stata 12.1. RESULTS: Of the 228 patients with mean age of 64.2±10.8 years, 109(47.8%) with a maen age of 65.4±11.6 had undergone percutaneous coronary intervention, and 119(52.2%) with a mean age of 64.2±10.8 years had undergone coronary artery bypass graft. Overall mortality was 36(15.8%) patients; 15(13.7%) percutaneous coronary intervention, 21(17.6%)coronary artery bypass graft (p>0.05). Predictors of in-hospital adverse events were coronary artery bypass graft and cardiogenic shock (p<0.05). Follow-up was available in 181(94.3%) patients with a mean duration of 22.0±13.9 months. Heart failure and post-procedure stroke were independent predictors of late outcome (p<0.05). CONCLUSIONS: Among patients with severe chronic kidney disease or end stage renal disease undergoing revascularisation, percutaneous coronary intervention PCI was performed in patients with less complex anatomy or as emergency for acute ST-elevation myocardial infarction. Coronary artery bypass graft patients had higher early mortality, but improved late survival.

Compliance of smokeless tobacco supply chain actors and products with tobacco control laws in Bangladesh, India and Pakistan: protocol for a multicentre sequential mixed-methods study.

INTRODUCTION: South Asia is home to more than 300 million smokeless tobacco (ST) users. Bangladesh, India and Pakistan as signatories to the Framework Convention for Tobacco Control (FCTC) have developed policies aimed at curbing the use of tobacco. The objective of this study is to assess the compliance of ST point-of-sale (POS) vendors and the supply chain with the articles of the FCTC and specifically with national tobacco control laws. We also aim to assess disparities in compliance with tobacco control laws between ST and smoked tobacco products. METHODS AND ANALYSIS: The study will be carried out at two sites each in Bangladesh, India and Pakistan. We will conduct a sequential mixed-methods study with five components: (1) mapping of ST POS, (2) analyses of ST samples packaging, (3) observation, (4) survey interviews of POS and (5) in-depth interviews with wholesale dealers/suppliers/manufacturers of ST. We aim to conduct at least 300 POS survey interviews and observations, and 6-10 in-depth interviews in each of the three countries. Data collection will be done by trained data collectors. The main statistical analysis will report the frequencies and proportions of shops that comply with the FCTC and local tobacco control policies, and provide a 95% CI of these estimates. The qualitative in-depth interview data will be analysed using the framework approach. The findings will be connected, each component informing the focus and/or design of the next component. ETHICS AND DISSEMINATION: Ethical approvals for the study have been received from the Health Sciences Research Governance Committee at the University of York, UK. In-country approvals were taken from the National Bioethics Committee in Pakistan, the Bangladesh Medical Research Council and the Indian Medical Research Council. Our results will be disseminated via scientific conferences, peer-reviewed research publications and press releases.

Protocol for a feasibility study of longitudinal surveys to assess the impact of policies on tobacco use among school-going adolescents in South Asia.

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world's 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among secondary school students to evaluate existing tobacco control policies on ST uptake and use, and a feasibility study for that prospective, observational cohort study. Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To assess if the questionnaire can assess tobacco uptake and use, and the potential predictors of tobacco uptake and use of the envisaged main study. Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible secondary schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among secondary school students, one year apart. At each time point, data on tobacco uptake and the potential predictors will be collected from students via self-administered questionnaires. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers. Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.

Mortality and deciding factors for no revascularization in cardiogenic shock patients; a cross sectional study.

OBJECTIVE: To assess the frequency of acute coronary syndrome patients with cardiogenic shock and not undergoing revascularisation, their in- hospital outcome and reasons underlying management decisions. METHODS: The retrospective cross-sectional study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2017 of acute coronary syndrome with hypotension and not having under gone revascularisation. Data was analyzed using Stata 12.1. RESULTS: Of the 383 patients, 55(14.3%) did not undergo revascularisation. Overall mean age was 63.2±9.8years. Overall mortality was 45(81.8%). Revascularisation was intended in 28(51%) patients of whom 19(68%) died before undergoing cardiac catheterisation. Another 9(32%) patients died after cardiac catheterisation but before revascularisation. Common clinical reasons in the remaining 27(49%) patients not considered for revascularisation were hypoxic brain injury secondary to cardiac arrest, patient refusal, perceived patient frailty, multi-organ failure, sepsis or pre-existing stroke/ malignancy. CONCLUSIONS: Cardiogenic shock complicating myocardial infarction not treated by revascularization had a very poor early outcome. In the two-third of patients before treatment was initiated, there was cardiac arrest with failed resuscitation or poor recovery.