Epidemiology of patients presenting to the emergency department with acute febrile illness in the summer months in Karachi, Pakistan: a cross-sectional study.

Low and middle-income countries, including Pakistan, encounter many acute, undifferentiated fevers in their emergency departments (EDs), especially in the summer. There is a need to understand the prevalence and etiologies of fever to create sustainable risk stratification systems and better identification processes for more efficient treatments. This study aims to determine the patterns, causes, and outcomes of patients presenting to the ED with a fever in the summer months in Karachi, Pakistan. Patients and methods: This was a cross-sectional surveillance study conducted in the summers of 2017 and 2018 in the EDs of four tertiary care hospitals in Karachi, Pakistan. Patients 18 years of age and older, both males and females, that presented with a fever within 48 h were enrolled in the study. The study sample was 5034. Prior comorbidities, medication history, and treatment offered for the illness and diagnosis were noted. The data were stratified by years, that is, 2017-2018. A χ 2-test and a one-way analysis of variance test were applied to check the association between fever presentation in years and covariates. Results: Of the 5034 patients, 3045 (60.5%) presented in 2017 and 1989 (39.5%) presented in 2018. Almost half of the patients who presented with fever to the ED were between 25 and 44 years of age [2383 (47.3%)]. A majority of those presenting were male [3049 (60.6%)]. Most of the patients had a fever recorded between 101 and 102°F [1038 (20.6%)]. The most common accompanying symptoms were headache [2636 (52.4%)] and nausea and vomiting [2274 (45.2%)]. The majority of the patients were diagnosed as viral fever [2390 (47.5%)]. Patients were managed with antibiotics [3342 (66.4%)] and intravenous fluids [2521 (50.1%)] and a majority of patients were discharged [4677 (93.8%)]. Conclusions: Fever is a common presentation in the ED. Understanding the frequency of the causative agent will help improve diagnosis and the judicious use of antibiotics.

To resuscitate or not to resuscitate? The crossroads of ethical decision-making in resuscitation in the emergency department.

Emergency physicians (EPs) working in low-resource settings, where patients mainly bear the cost of healthcare delivery, face many challenges. Emergency care is patient-centered and ethical challenges are numerous in situations where patient autonomy and beneficence are fragile. This review discusses some of the common bioethical issues in the resuscitation and postresuscitation phases of treatment. Solutions are proposed and the necessity for evidence-based ethics and unanimity on ethical standards is emphasized. After a consensus was reached on the structure of the article, smaller groups of authors (2-3) wrote narrative reviews of ethical issues such as patient autonomy and honesty, beneficence and nonmaleficence, dignity, justice, and specific practices and circumstances such as family presence during resuscitation after discussions with senior EPs. Ethical dilemmas were discussed, and solutions were proposed. Cases related to medical decision-making by proxy, financial constraints in management, and resuscitation in the face of medical futility have been discussed. Solutions proposed include the early-stage involvement of hospital ethics committees, financial assurance in place beforehand, and allowing some leverage on a case-to-case basis when care is futile. We recommend developing evidence-based national ethical guidelines and incorporating societal and cultural norms with autonomy, beneficence, nonmaleficence, honesty, and justice principles.

Development of COVID-19 severity assessment score in adults presenting with COVID-19 to the emergency department.

BACKGROUND: Critically-ill Covid-19 patients require extensive resources which can overburden a healthcare system already under strain due to a pandemic. A good disease severity prediction score can help allocate resources to where they are needed most. OBJECTIVES: We developed a Covid-19 Severity Assessment Score (CoSAS) to predict those patients likely to suffer from mortalities within 28 days of hospital admission. We also compared this score to Quick Sequential Organ Failure Assessment (qSOFA) in adults. METHODS: CoSAS includes the following 10 components: Age, gender, Clinical Frailty Score, number of comorbidities, Ferritin level, D-dimer level, neutrophil/lymphocyte ratio, C-reactive Protein levels, systolic blood pressure and oxygen saturation. Our study was a single center study with data collected via chart review and phone calls. 309 patients were included in the study. RESULTS: CoSAS proved to be a good score to predict Covid-19 mortality with an Area under the Curve (AUC) of 0.78. It also proved better than qSOFA (AUC of 0.70). More studies are needed to externally validate CoSAS. CONCLUSION: CoSAS is an accurate score to predict Covid-19 mortality in the Pakistani population.

Vitamin D (Cholecalciferol) with Low Dose Vitamin C as a Safe and Effective Therapeutic Modality in an Adult with COVID-19 Pneumonia.

This is a case of an elderly female presenting with fever, cough and shortness of breath. On presentation, she had tachypnea and an oxygen requirement of 2 liters through nasal prongs. Her investigations were suggestive of COVID-19 pneumonia with bilateral ground-glass appearance on chest X-ray and a positive nasopharyngeal PCR swab. She had low vitamin D levels on presentation and was given 200,000 units of cholecalciferol, once daily for 3 days with Vitamin C, 500 mg per oral once daily for 7 days. Her symptoms got progressively better and her oxygen requirement diminished on next day. On day 3, her symptoms completely resolved, and her chest X-ray improved. In patients with COVID-19 pneumonia, who are vitamin D deficient, administration of large doses of cholecalciferol for few days can be a safe option to treat mild to moderate COVID-19 pneumonia. Key Words: Vitamin D, COVID-19, Pneumonia, Vitamin C.

Paediatric innovation in Pakistan: our experience and a call to action.

Standardisation in paediatric medicine may have the unintended effect of stifling innovation. Thinking outside the box becomes even more important in low-income to middle-income countries like Pakistan, where a large paediatric population requires healthcare. In addition, there is always a lack of funds, making an innovative, low-cost and high impact solution all the more necessary. While regulation and formal research is an integral part of the process, the local synthesis of a solution must start with a creative idea. To address the dearth of avenues promoting lateral thinking relevant to biomedicine and healthcare among students and faculty, the Critical Creative Innovative Thinking forum was formed at the Aga Khan University in Karachi, Pakistan, by a group consisting of students and faculty in 2014. The primary objective of the forum was to provide an arena conducive to lateral thinking and to equip biomedical professionals with the skill set to enable and promote creativity and innovation. This paper seeks to outline those efforts and discuss their potential impact on paediatric care for resource-limited settings.

Status of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan.

The ability of pathogenic free-living amoebae to produce infections is a growing concern. In this study, we investigated the presence of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan. Fifty-two domestic tap water samples were examined. Amoebae were identified by morphological characteristics and polymerase chain reaction. Thirty percent of the examined samples were positive for Acanthamoeba spp., 8% for N. fowleri while B. mandrillaris were not recovered. Additionally we examined secretory IgA antibody to Acanthamoeba and B. mandrillaris. Acanthamoeba antibody prevalence rate was 100% in both males and females, while B. mandrillaris antibody prevalence rate was 5.5% in males only (females were negative). Our findings suggest that free-living amoebae are a potential health hazard in domestic water supplies in Karachi, Pakistan.