Comparison of five different disseminated intravascular coagulation criteria in predicting mortality in patients with sepsis.

OBJECTIVE: Even though patients with sepsis and DIC have a higher mortality rate compared to those without DIC, screening for DIC is not currently part of sepsis management protocols. This may be due to a lack of literature on the frequency of DIC occurrence in sepsis patients, as well as the absence of evidence on the optimal DIC criteria to use for identifying DIC and predicting mortality among the five criteria available. To address this gap, this study investigates the predictive value of five different criteria for diagnosing DIC and its relationship to patient outcomes in our population of sepsis patients. METHODS: In the Medicine department of Aga Khan University Hospital, a retrospective observational study was conducted, enrolling all adult patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding of sepsis and clinical suspicion of DIC between January 2018 and December 2020. To diagnose DIC, five different criteria were utilized, namely the International Society of Thrombosis and Hemostasis (ISTH), the Korean Society on Thrombosis and Hemostasis (KSTH), the Japanese Association for Acute Medicine (JAAM), the revised-JAAM (RJAAM), and the Japanese Ministry of Health and Welfare (JMHW). The study analyzed the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of these five criteria, as well as the overall prediction of mortality. RESULTS: Of 222 septic patients included in this study with clinical suspicion of DIC, 94.6% of patient had DIC according to KSTH criteria, followed by JAAM (69.4%), ISTH (64.0%), JMHW (53.2%) and lastly R-JAAM (48.6%). KSTH had sensitivity of 95.4% in diagnosing DIC and predicting mortality with a positive predictive value of 70% but specificity of 7.3% only. JAAM had sensitivity of 75.9%, positive predictive value of 75.9% with a specificity of 45.5%. ISTH had sensitivity of 69.4%, positive predictive value 75.3% and specificity of 48.5%. CONCLUSION: DIC can impose a significant burden on septic patients and its presence can lead to higher mortality rates. Early detection through screening for DIC in septic patients can potentially reduce mortality. However, it is necessary to identify the most appropriate diagnostic criteria for each population, as various criteria have demonstrated different performance in different populations. Establishing a gold standard for each population can aid in accurate diagnosis of DIC.

Covid-19 co-infection with Crimean Congo haemorrhagic fever (CCHF) in a CCHF endemic country: a case report.

Covid-19 pandemic affected the health care systems globally. In many countries, healthcare services were overwhelmed by the huge number of Covid cases; hence, shifting the focus from locally endemic infectious diseases. Such a case presented to us that was initially managed along the lines of critical Covid pneumonia with steroids, Remdesivir, and supplemental oxygen for hypoxic respiratory failure. The patient also received Baricitinib, to which he was non-responsive and thus offered invasive mechanical ventilation. Post intubation, the patient was managed for Covid-associated ARDS with lung protective ventilation. He later also developed liver dysfunction, renal failure, coagulation derangements, and shock. Workup for malaria and dengue were negative. Later, Crimean Congo PCR was sent which came positive; a possible cause of progressive deterioration. In CCHF endemic areas, it is crucial to rule out the CCHF infection among patients presenting with critical Covid pneumonia due to similar clinical presentation in both the infections.

Bedbug infestation in Lahore hospitals

Background: Bedbug infestation has been reported globally, but there are few reports about this parasite of public health importance in Pakistan. This is the first study on bedbug infestation in a healthcare setting in Lahore, Pakistan. Aims: To study bedbug infestation in public sector hospitals in Lahore, Pakistan. Methods: This cross-sectional study was conducted in 86 wards of 2 tertiary care hospitals in Lahore during October and November 2019, using nonprobability sampling technique. Ward supervisors were interviewed using a self-developed structured questionnaire and wards were examined for bedbugs or their markers. Results: Evidence of bedbug infestation was found in 72.1% of the wards. There was no significant difference in infestation rate between the 2 hospitals but there was a significantly lower incidence of infestation in wards that implemented control measures (25.8% vs 74.2%). No control measures were implemented in 53.4% of the wards sampled. Conclusion: Bedbug infestation was rife in the 2 hospitals studied and knowledge about identification and eradication of the pest among ward supervisors was inadequate. Control measures, where applied, were substandard and not evidencebased.

Telemedicine for Rheumatology Patients in Covid-19 Pandemic: Perspectives of Patients.

Telemedicine use for patients with autoimmune rheumatic conditions during the pandemic mandates better characterization. We conducted a telephonic survey on patients who consulted rheumatologists remotely to determine their attitudes toward telemedicine. The study was conducted at Aga Khan University Hospital, a tertiary care hospital in Pakistan which is a lower-middle-income country. Descriptive analyses were performed. Fifty patients visited tele-rheumatology clinic, 35 (70.0%) were female with a mean (SD) age of 47.6 (18.1) years. Majority (27, 54.0%) learned about telemedicine from hospital website and outpatient clinic desk or helpline. Lack of examination was the biggest concern with teleconsultation (18, 22.2%). Most patients (38, 76.0%) agreed to continue teleconsultation beyond the pandemic. Telemedicine is preferable for providing rheumatology outpatient service during and after the pandemic.

Assessment of Trauma Care Capacity in Karachi, Pakistan: Toward an Integrated Trauma Care System.

BACKGROUND: Pakistan is a lower-middle-income country with a high burden of injuries. Karachi, its most populated city, lacks a trauma care system due to which trauma patients do not receive the required care. We conducted an assessment of the existing facilities for trauma care in Karachi. METHODS: Twenty-two tertiary and secondary hospitals from public and private sectors across Karachi were assessed. The Guidelines for Essential Trauma Care (GETC) tool was used to collect information about the availability of skills, knowledge, and equipment at these facilities. RESULTS: Among tertiary hospitals (n = 7), private sector hospitals had a better median (IQR) score, 90.4 (81.8-93.1), as compared to the public sector hospitals, 44.1 (29.3-75.8). Among secondary hospitals (n = 15), private sector hospitals had a better median (IQR) score, 70.3 (67.8-77.7), as compared to the public sector hospitals, 39.7 (21.9-53.3). DISCUSSION: This study identifies considerable deficiencies in trauma care in Karachi and provides objective data that can guide urgently needed reforms tailored to this city's needs. On a systems level, it delineates the need for a regulatory framework to define trauma care levels and designate selected hospitals across the city accordingly. Using these data, improvement in trauma care systems can be achieved through collaboration and partnership between public and private stakeholders.

Free flap reconstruction after lower limb trauma - outcome analysis using National Surgical Quality Improvement Programme (NSQIP) parameters.

OBJECTIVE: To assess the outcomes of free flap reconstructions performed for the management of lower limb trauma. METHODS: This retrospective study was conducted at Aga Khan University Hospital (AKUH), Karachi and included data from June 2017 to May 2019 of patients who underwent free flap reconstruction as part of management of lower limb trauma. RESULTS: The mean age of the 8 adult patients was 34±11 years. Also included were two paediatric patients aged 7 and 8 years. Nine of the total 10 patients were male. Road traffic accidents were the most common mechanism of injury, occurring in 5(50%), followed by blast injuries in 3(33%). The anterolateral thigh flap was the most common type of flap used for reconstruction, done in 8(80%) patients. Flap survival rate was 90% and full flap loss was seen in only 1(10%) patient. Re-exploration surgery was done in 5(50%) patients during the same hospital stay. The length of hospital stay varied greatly from 4 to 105 days depending on associated diagnoses and whether the free flap surgery was performed during an elective admission. One patient did not survive to discharge, and the cause of death was attributed to septic complications. Functional outcomes on follow-up could not be determined. CONCLUSIONS: Free flap reconstruction surgery is an effective solution for management of lower limb trauma and has a high flap survival rate. Further studies are needed to ascertain the functional outcomes of limb salvage after free flap surgery.

A Model to Determine Value of Care Delivered at the Level of Individual Providers in an Organization.

Introduction: Value in health care has been defined as health outcomes achieved per dollar spent. The concept of value is a shift from the traditional volume-based health delivery system. The implementation of value-based health care has generally been at an institutional level. The objective of our study was to calculate and compare the value of health care delivered by nine individual surgeons at a single institution for laparoscopic cholecystectomies, at the level of the provider. Methods: Data were collected for laparoscopic cholecystectomies performed over 2 years from January 1, 2016, to December 31, 2017. Only elective cholecystectomies performed for noninflamed gall bladder were included in the analysis. Any patients admitted through the emergency department were excluded. Patients who had comorbidities requiring further workup after admission were also excluded. To the best of our knowledge, there is no published model for determining value at the level of the provider. Hence, we devised a formula to determine the value of health care provided by individual surgeons based on outcome 30 days after laparoscopic cholecystectomy: Value = Positive outcome score/Cost of care. Results: A total of 1840 cholecystectomies were performed by nine surgeons in the study period, out of which 1402 met the selection criteria. There was a significant variation in the value provided by different surgeons according to our model. Conclusion: Our proposed model differentiated the value provided by individual surgeons. Validation of the model on prospectively collected data is the way forward. The key points are: (1) There is a shift from volume-based healthcare to value-based healthcare (VBHC). (2) There is paucity of data about value provided by individual providers. (3) We propose a method of calculating and differentiating value provided by individual providers.

A cobalt oxide nanocubes interleaved reduced graphene oxide nanocomposite modified glassy carbon electrode for amperometric detection of serotonin.

Cobalt oxide nanocubes incorporated with reduced graphene oxide (rGO-Co3O4) was prepared by using simple one-step hydrothermal route. Crystallinity and structural characteristics of the nanocomposite were analyzed and confirmed using X-ray diffraction (XRD) and Raman analysis, respectively. The cubical shape of the Co3O4 nanostructures and the distribution of Co3O4 nanocubes on the surface of rGO sheets were identified through field emission scanning electron microscopy (FESEM) and energy dispersive X-ray (EDX) mapping analysis, respectively. Raman spectra depicted the presence of D and G bands for GO and rGO with different ID/IG values and thus confirmed the reduction of GO into rGO. The electrochemical study reflects that the rGO-Co3O4 nanocomposite shows good electrocatalytic activity in oxidation of depression biomarker serotonin (5-HT) in phosphate buffer (pH 7.2). The detection of 5-HT was carried out by using rGO-Co3O4 nanocomposite modified glassy carbon electrode under dynamic condition using amperometry technique with a linear range of 1-10 µM. The limit of detection and limit of quantification were calculated and found to be 1.128 and 3.760 µM, respectively with a sensitivity value of 0.133 µΑ·µM-1. The sensor showed selectivity in the presence of different interferent species such as ascorbic acid, dopamine and uric acid.

Significantly improved photovoltaic performance in polymer bulk heterojunction solar cells with graphene oxide /PEDOT:PSS double decked hole transport layer.

This work demonstrates the high performance graphene oxide (GO)/PEDOT:PSS doubled decked hole transport layer (HTL) in the PCDTBT:PC71BM based bulk heterojunction organic photovoltaic device. The devices were tested on merits of their power conversion efficiency (PCE), reproducibility, stability and further compared with the devices with individual GO or PEDOT:PSS HTLs. Solar cells employing GO/PEDOT:PSS HTL yielded a PCE of 4.28% as compared to either of individual GO or PEDOT:PSS HTLs where they demonstrated PCEs of 2.77 and 3.57%, respectively. In case of single GO HTL, an inhomogeneous coating of ITO caused the poor performance whereas PEDOT:PSS is known to be hygroscopic and acidic which upon direct contact with ITO reduced the device performance. The improvement in the photovoltaic performance is mainly ascribed to the increased charge carriers mobility, short circuit current, open circuit voltage, fill factor, and decreased series resistance. The well matched work function of GO and PEDOT:PSS is likely to facilitate the charge transportation and an overall reduction in the series resistance. Moreover, GO could effectively block the electrons due to its large band-gap of ~3.6 eV, leading to an increased shunt resistance. In addition, we also observed the improvement in the reproducibility and stability.

Women with pregnancy induced hypertension have a higher risk of developing essential hypertension - a case control study from a tertiary care center in Pakistan.

OBJECTIVE: To determine the association of essential hypertension with pregnancy-induced hypertension in women. METHODS: The case-control study was conducted at Aga Khan University Hospital, Karachi, from January 2012 to March 2013, and comprised on hypertensive female patients who visited the outpatient medicine clinics. The patients were aged 18-65 years and had been pregnant atleast once. Cases were women diagnosed as hypertensive or pre-hypertensive and the controls were normotensive women. The primary outcome was essential hypertension and the main exposure was pregnancy-induced hypertension. RESULTS: Of the 258 subjects, 175(49.7%) were cases and 177(50.3%) were controls. The overall mean age was 44.6±13.3 years. Odds Ratio (95% Confidence interval) for pregnancy-induced hypertension for the outcome of essential hypertension was 1.6 (0.88, 3.0). The odds ratio increased further to 2.5(1.2, 5.2) after adjustment for age, family history of hypertension and physical activity. The association remained after further adjusting for body mass index in the final model; 2.20 (1.06, 4.57). CONCLUSIONS: Women who develop hypertension in pregnancy are at higher risk of developing essential hypertension later in life.

Clinical characteristics and predictors of positive stool culture in adult patients with acute gastroenteritis.

OBJECTIVE: To identify the presenting features and spectrum of pathogens in adult patients with acute diarrhoea and to determine the predictors of stool culture positivity. METHODS: A descriptive study was conducted in a tertiary care hospital from April 1, 2005 to March 31, 2006. Medical records of all consecutive adult patients with history of acute diarrhoea were reviewed between June 2006 to December 2006 for clinical characteristics and laboratory investigations. RESULTS: A total of 454 patients were admitted from April 1, 2005 to March 31, 2006. Stool cultures were performed in 233 (50%) patients, 96 (42%) had positive results. Patients with positive stool culture compared to a negative Culture were found to have a younger mean age (43 vs. 53), greater number of unformed stools (16 vs. 11) and low serum bicarbonate level (16 vs. 20). Vibrio cholerae (86%) was found to be the most prevalent organism followed by Salmonella spp (6%), Campylobacter spp (5.2%), Shigella spp (2%). Ciprofloxacin was given to 97% patients along with fluid administration, and 78% were found to be resistant to quinolones. Most patients recovered before the finalized stool culture results. CONCLUSION: Careful selection of the patients based on their clinical presentation and initial laboratory work up can help to decide ordering of stool culture in adults with diarrhoea. Fluid resuscitation remains the main stay of treatment.

Outbreak of dengue fever in Karachi 2006: a clinical perspective.

OBJECTIVE: This study reports clinical manifestations and spectrum of severity of dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) in adult patients admitted during 2006 outbreak in Karachi. A rough estimation of cost of care was also calculated. METHODS: A cross-sectional study was done at a tertiary care hospital in Karachi from January to December 2006. Patients suspected of having DF with positive dengue IgM antibodies were included and records were reviewed. Patients were divided into DF, DHF and DSS as per WHO classification, and the severity of clinical manifestations was determined. RESULTS: A total of 278 (65.72%) of 423 patients admitted with suspected dengue illness had positive IgM titer. Mean age was 31 +/- 12.9 years, with 168 (60%) males and 110 (40%) females. Common presenting symptoms were fever (100%), vomiting (78%), epigastric pain (52%), bleeding tendencies (34%), and erythematous rash (33%). Thrombocytopenia (60%), Leucopenia (45%), elevated transaminases (ALT 71%; AST 88%), and deranged PT (22%) and aPTT (75%) were the predominant. Laboratory parameters: DF was diagnosed in 169 (61%) patients, 82 (29%) were classified as DHF, and 27 (10%) as DSS. Patients with DHF/DSS were younger <30 years (n=60, 55%) and had longer hospital stay (p=0.001). Case fatality rate for DHF/DSS group was 4.6%. CONCLUSION: It was estimated that endemicity of DF is on the rise in Karachi and a significant proportion of patients had DHF and DSS. Younger patients develop DHF and DSS and have high case fatality rate.