Development, outcome and costs of a simulation-based neurosurgery bootcamp at the national level.

INTRODUCTION: With a growing interest in simulation-based training to develop clinical proficiency, bootcamps have been utilized for imparting basic skills to medical trainees. While considerable research on the topic exists in high income countries, no such neurosurgical teaching standards have been employed in Low- and Middle-Income Countries. METHODS: We conducted a cross-sectional study to explore the effectiveness of first low-cost, multi-center regional neurosurgery bootcamp in South Asia. Twenty-two participants attended the bootcamp and practiced 12 hands-on skills over the course of 2 days. Burr-holes and craniotomies were done on 3D printed skulls. Lumbar drain insertion was practiced on a purpose-built lumbar puncture mannequin. For laminectomy, we used an in-house designed simulation. The modified Objective Structured Assessment of Technical Skills tool was utilized for skills Assessment. Feedback from faculty and residents was collected via a standard 5-point Likert scale. RESULTS: Only one participant (4.55%) had previously attended a neurosurgical skills workshop. Comparison of outcomes on 1st and 3rd attempts of cranial and spinal skills showed a significant improvement in all 14 domains assessed (p <0.05). Positive feedback was received ranging from 3.9 up to 4.8 on a 5-point Likert scale. Overall cost per participant culminated to $145, significantly lower than previously reported data. CONCLUSION: Our findings report the effectiveness of sustainable, low-cost training models which can be easily reproduced elsewhere. These indigenously designed simulators can be modified for variable difficulty level and serve as an effective educational strategy in improving learners' skills, knowledge and confidence.

The impact of COVID-19 safety interventions on creating a controlled environment on campus.

Objectives: During COVID-19 the re-opening of educational institutes was frequently debated, however with the decline in the number of COVID-19 cases, The Aga Khan University (AKU) in Karachi, Pakistan opened its campus for medical and nursing students after more than 6 months of closure. To ensure gradual resumption of activities on-campus, a combination of interventions was diligently deployed to minimize student infection rates. Scarce literature exists on students' perceptions regarding decisions implemented by university leadership. The aim of the study was to determine the efficacy of these interventions. Methods: We conducted a convergent, parallel, mixed-methods observational study targeting medical and nursing students. An online questionnaire was disseminated to elicit students' degree of (dis)agreement on a four-point Likert scale. Focused group discussions (FGDs) were conducted to comprehend reasons for (dis)agreement. Results: Total of 183 students responded to questionnaire (59.0% nursing, 67.8% female), 11 FGDs were conducted with 85 students. Interventions with highest agreement were mandatory face masks policy (94.54%), weekly mandated COVID-testing (92.35%) and students' Academic Bubble (91.26%); highest disagreement was for Sehat Check application (41.53%); and stay strong campaign (40.44%). Four themes emerged from FGDs: Effective safety interventions, Safety interventions with limited effectiveness, Utility of Sehat Check Application and Future recommendations for informing policy. Conclusion: It is paramount to seek student-feedback at forefront of university re-opening strategy. Clear communication channels are as important as an administrative response system's robustness. Bidirectional communication channels are fundamental and requisite during ever-changing policies and regulations. Engaging student representatives in decision making or implementation processes (such as "pilot" before "roll-out") would allow any potential issues to be managed early on. Gather real-time anonymous feedback and identify key areas that need further promulgation and those that need to be replaced with more effective ones.

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system.

BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.

Corrigendum: A Nationwide Virtual Research Education Program for Medical Students in Pakistan: Methodological Framework, Feasibility Testing, and Outcomes.

[This corrects the article DOI: 10.3389/fpubh.2021.812130.].

A Nationwide Virtual Research Education Program for Medical Students in Pakistan: Methodological Framework, Feasibility Testing, and Outcomes.

Introduction: Equipping young medical trainees with fundamental research skills can be a promising strategy to address the need for professionals who can understand and responsibly communicate evolving scientific evidence during a pandemic. Despite an ardent interest to partake in research, most educational institutions in Pakistan and other low-middle income countries have not yet adopted a comprehensive strategy for research skills education. The authors aimed to design and assess the feasibility of implementing the first nation-wide virtual research workshop for medical students in Pakistan. Methods: The course "Beginners Guide to Research," designed as a nation-wide virtual research workshop series, was conducted for medical students across Pakistan in June 2020. Four interactive live workshops took place online on alternate days from June 22nd, 2020, to June 27th, 2020, each lasting 1-2 h. Outcomes included: (i) reach, (ii) efficacy as indexed by pre-post change in score pertaining to knowledge and application of research and (iii) self-rated perceptions about understanding of research on a Likert scale. Results: 3,862 participants enrolled from 41 cities and 123 institutions. Enrolled participants belonged to the following provinces: Sindh (n = 1,852, 48.0%), Punjab (n = 1,767, 45.8%), Khyber Pakhtunkhwa (n = 109, 2.8%), Azad Jammu and Kashmir (n = 84, 2.2%) Balochistan (n = 42, 1.1%). We also saw a few registrations from international students (n = 8, 0.2%). Mean (SD) age of enrolled medical students was 21.1 (2.1) years, 2,453 (63.5%) participants were female and 2,394 (62.0%) were from private-sector medical colleges. Two thousand ninety-three participants participants filled out all four pre-test and post-test forms. The total median knowledge score improved from 39.7 to 60.3% with the highest improvements in concepts of research bioethics and literature search (p < 0.001) with greater change for females compared to males (+20.6 vs. +16.2%, p < 0.001) and private institutions compared to public ones (+16.2 vs. +22.1%, p < 0.001). Conclusion: The overwhelming enrollment and significant improvement in learning outcomes (>50% of baseline) indicate feasibility of a medical student-led research course during a pandemic, highlighting its role in catering to the research needs in the LMICs.

Development and validation of a revised trauma-specific quality of life instrument.

BACKGROUND: The National Academies of Science has called for routine collection of long-term outcomes after injury. One of the main barriers for this is the lack of practical trauma-specific tools to collect such outcomes. The only trauma-specific long-term outcomes measure that applies a biopsychosocial view of patient care, the Trauma Quality-of-Life (T-QoL), has not been adopted because of its length, lack of composite scores, and unknown validity. Our objective was to develop a shorter version of the T-QoL measure that is reliable, valid, specific, and generalizable to all trauma populations. METHODS: We used two random samples selected from a prospective registry developed to follow long-term outcomes of adult trauma survivors (Injury Severity Score ≥9) admitted to three level I trauma centers. First, we validated the original T-QoL instrument using the 12-Item Short-Form Health Survey (SF-12) version 2.0 and Breslau post-traumatic stress disorder screening (B-PTSD) tools. Second, we conducted a confirmatory factor analysis to reduce the length of the original T-QoL instrument, and using a different sample, we scored and performed internal consistency and validity assessments of the revised T-QoL (RT-QoL) components. RESULTS: All components of the original T-QoL were significantly correlated negatively with the B-PTSD and positively with the SF-12 mental and physical composite scores. After confirmatory factor analysis, a three-component structure using 18 items (six items/component) most appropriately represented the data. Each component in the revised instrument demonstrated a high level of internal consistency (Cronbach's α ≥0.8) and correlated negatively with the B-PTSD and positively with the SF-12, demonstrating concurrent validity. In addition, each of the RT-QoL components was able to distinguish between individuals based on their work status, with those who have returned to work reporting better health. CONCLUSION: This more practical RT-QoL measure greatly increases the ability to evaluate long-term outcomes in trauma more efficiently and meaningfully, without sacrificing the validity and psychometric properties of the original instrument. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Association of pain after trauma with long-term functional and mental health outcomes.

BACKGROUND: Chronic pain after trauma is associated with serious clinical, social, and economic burden. Due to limitations in trauma registry data and previous studies, the current prevalence of chronic pain after trauma is unknown, and little is known about the association of pain with other long-term outcomes. We sought to describe the long-term burden of self-reported pain after injury and to determine its association with positive screen for posttraumatic stress disorder (PTSD), functional status, and return to work. METHODS: Trauma survivors with moderate or severe injuries and one completed follow-up interview at either 6 months or 12 months after injury were identified from the Functional Outcomes and Recovery after Trauma Emergencies project. Multivariable logistic regression models clustered by facility and adjusting for confounders were used to obtain the odds of positive PTSD screening, not returning to work, and functional limitation at 6 months and 12 months after injury, in trauma patients who reported to have pain on a daily basis compared to those who did not. RESULTS: We completed interviews on 650 patients (43% of eligible patients). Half of patients (50%) reported experiencing pain daily, and 23% reported taking pain medications daily between 6 months and 12 months after injury. Compared to patients without pain, patients with pain were more likely to screen positive for PTSD (odds ratio [OR], 5.12; 95% confidence interval [CI], 2.97-8.85), have functional limitations for at least one daily activity (OR, 2.42; 95% CI, 1.38-4.26]), and not return to work (OR, 1.86; 95% CI, 1.02-3.39). CONCLUSIONS: There is a significant amount of self-reported chronic pain after trauma, which is in turn associated with positive screen for PTSD, functional limitations, and delayed return to work. New metrics for measuring successful care of the trauma patient are needed that span beyond mortality, and it is important we shift our focus beyond the trauma center and toward improving the long-term morbidity of trauma survivors. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Angiographic embolization for major trauma in a low-middle income healthcare setting--A retrospective review.

INTRODUCTION: Interventional radiology (IR) provides a range of adjunctive techniques to assist with hemorrhage control after trauma that can be employed pre- or post-operatively. The role of IR in lower-middle income countries (LMICs) remains unexplored. This study describes the use of adjunctive angioembolization (AE) in severely injured patients following its recent implementation at an urban trauma center in a LMIC. METHODS: Adult patients (≥ 16 years) requiring AE from 2011 to 2013 at a single trauma-care facility were included. Data was collected on demographic parameters, transfer status, injury severity score (ISS), emergency resuscitation characteristics, AE and operative characteristics, complications, and in-hospital mortality. Descriptive analyses were performed. RESULTS: Thirty six patients underwent AE for trauma-related hemorrhagic complications and were included in the study. Average age was 31.5 (± 11.3) years with a male preponderance (91.7%). Penetrating trauma (61.1%) was the most common type of injury. The primary mechanism of injury was gunshot (58.3%). The median ISS was 24 (IQR: 20-29). Pre-operative AE was performed in 23 (63.9%) patients and these patients had a lower median ISS (22) than those who underwent post-operative AE (p = 0.015). Hepatic (55.6%) and pelvic (33.3%) trauma more commonly required radiological intervention. Bleeding from the right hepatic (n = 14), and the right internal iliac (n = 6) arteries and/or their branches, were more often embolized. Microcoils were the preferred AE agents (61.1%). Median length of hospital stay was 7.5 (IQR: 3-14) days. Eight (22.2%) patients did not survive. CONCLUSION: With the availability of multi-detector computed tomography and a dedicated interventional radiology suite, implementation of AE for the care of trauma patients in LMIC settings is possible.

National estimates of predictors of outcomes for emergency general surgery.

BACKGROUND: Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients. METHODS: The Nationwide Inpatient Sample (2003-2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases-9th Rev.-Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size). RESULTS: This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20-1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84-0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. CONCLUSION: Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery's previous success. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system.

INTRODUCTION: Pre-hospital triage is an intricate part of any mass casualty response system. However, in settings where no such system exists, it is not known if hospital-based disaster response efforts are beneficial. This study describes in-hospital disaster response management and patient outcomes following a mass casualty event (MCE) involving 200 victims in a lower-middle income country in South Asia. METHODS: We performed a single-center, retrospective review of bombing victims presenting to a trauma center in the spring of 2013, after a high energy car bomb leveled a residential building. Descriptive analysis was utilized to present demographic variables and physical injuries. RESULTS: A disaster plan was devised based on the canons of North-American trauma care; some adaptations to the local environment were incorporated. Relevant medical and surgical specialties were mobilized to the ED awaiting a massive influx of patients. ED waiting room served as the triage area. Operating rooms, ICU and blood bank were alerted. Seventy patients presented to the ED. Most victims (88%) were brought directly without prehospital triage or resuscitation. Four were pronounced dead on arrival. The mean age of victims was 27 (±14) years with a male preponderance (78%). Penetrating shrapnel injury was the most common mechanism of injury (71%). Most had a systolic blood pressure (SBP) >90 with a mean of 120.3 (±14.8). Mean pulse was 90.2 (±21.6) and most patients had full GCS. Extremities were the most common body region involved (64%) with orthopedics service being consulted most frequently. Surgery was performed on 36 patients, including 4 damage control surgeries. All patients survived. CONCLUSION: This overwhelming single mass-casualty incident was met with a swift multidisciplinary response. In countries with no prehospital triage system, implementing a pre-existing disaster plan with pre-defined interdisciplinary responsibilities can streamline in-hospital management of casualties.