Aga Khan University Hospital Karachi Research Articles

Frequency of tracheal intubation associated adverse events and contributing factors in the Pediatric Intensive Care Unit (PICU).

Objective: To determine the frequency of adverse events associated with immediate tracheal intubation in children (1-18 years) from Pediatric Intensive Care Unit of Tertiary Care Hospital of Karachi, Pakistan. Study Design: Observational study. Setting: PICU of the Aga Khan University Hospital Karachi. Period: September 2020 to August 2021. Methods: A total of 183 intubations occurred during the study period. Data was extracted using the pre-designed peri-intubation proforma, data recorded on the checklist by the observer (Staff) who was fully trained by the Physician, later on compared by the researcher using the video recorded laryngoscopy used during the intubation procedure. Results: There were 183 intubations occurred during study period. Maximum intubations were in age group of 1-5 years (27.3%) and among total intubations, there were 11(6%) intubation related complications occurred. 6 (3.3%) cases have hypoxia, 3 (1.6%) bradycardia and 2 (1.1%) others (hypotension and esophageal intubation). Majority of the complications were observed during morning hours with statistically significant association. 63.60% TI related cases survived whereas 36.40% of them expired, 54.5% stayed in PICU for 0-10 days. Conclusion: Tracheal intubation related adverse events were 6% and majority of them lead to hypoxia. Physiological and mechanical complications with the procedure do occur inspite of our best efforts. Recognizing the complications associated with tracheal intubation can help physicians better care for patients requiring intubation.

Comparison of pre and post Foley catheter Bishop's Score: A retrospective record review at Aga Khan University Hospital Karachi, Pakistan.

To compare pre and post Foley's catheter Bishop Score during labour induction. This study was a retrospective study conducted at the Aga Khan University Hospital Karachi, Pakistan after approval from ethical review board. All women who underwent induction of labour with Foley's Catheter at gestation of 37 weeks or more from September 2014-October 2015 were included. Data was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 19.0. The comparison between pre and post Foley's catheter Bishop Score during labour induction will be calculated by Wilcoxon sign test. There were 981 cases of inductions of labour, 749 (76.3%) received Foley's catheter, in combination with prostaglandins and oxytocin. About 68% were vaginal deliveries while 32% underwent C-section. Two third of women had bishop <4. Overall, Bishop score improved significantly in all patients with the catheter however, maximum benefit was seen in patients where the catheter was placed for 10-12 hours. Foley's is the better and safer option. In view of our results, It has been recommended to keep the Foley's for 10-12 hours to get significant improvement in bishop score.

Post-tuberculous meningitis hydrocephalous- A case report

Mycobacterium tuberculous bacteria infect host lungs while inhaling them from the external environment, causing a localized infection with a potential to spread to local lymph nodes. The bacilli have the property to disseminate to other organs including Central Nervous System (CNS) and lead to tuberculous meningitis (TBM). The bacilli may develop tiny sub-pial or sub-ependymal rich foci. These rich foci get larger as the illness worsens and may finally burst into the sub-arachnoid region, causing meningitis. Tuberculous meningitis is linked to a high mortality rate. The majority of TBM patients who survive have long term neurological disabilities. This case was presented to Aga Khan University Hospital Karachi, Pakistan and the patient has taken Leave Against Medical Advice twice due to financial crises.

Accuracy of Diffusion Weighted Imaging in Assessment of Pelvic Lymphnode Metastasis in Patients with Endometrial Cancer.

To evaluate the sensitivity and specificity of diffusion-weighted imaging in determining metastatic pelvic lymph nodes in patients of endometrial cancer and comparing its accuracy with contrast-enhanced sequence of MRI, taking histopathology as gold standard. Retrospective Study. Place and Duration of the Study: Department of Radiology, the Aga Khan University Hospital Karachi, from January to December 2021. Fifty-eight adult females with biopsy proven endometrial carcinoma and complete medical records were included through convenience sampling. Patients who did not have complete medical records were excluded. Studied variables included signal characteristics of lymph nodes and their short axis diameter. The sensitivity and specificity of DWI and contrast-enhanced MRI for evaluation of diseased lymph nodes were calculated using histopathology as the gold standard. Among 58 patients with histopathologically proven endometrial cancer, 14 had metastatic lymphadenopathy. DWI-weighted imaging in the evaluation of metastatic and non-metastatic lymph nodes had sensitivity of 81.1% while specificity, the positive and negative predictive value of 88.8%, 72.2%, and 82.5% and on contrast-enhanced imaging as 66.6%, 58.1%, 35.7%, and 83.3%, respectively. The DWI shows better accuracy in evaluation and discrimination between metastatic and non-metastatic lymph nodes as compared to contrast-enhanced MRI examination for the evaluation of diseased lymph nodes in patients with endometrial cancer. DWI, Contrast-enhanced MRI, Lymph node, Endometrial cancer.

Frequency of Resistance to Third Generation Cephalosporin in Neonates with Septicemia at a Tertiary Care Hospital

Background and Objective: Sepsis in newborns is a serious medical issue everywhere [1]. With an incidence of 1 to 10 per 1000 live births worldwide, newborns are more susceptible to developing bacterial sepsis [2]. With a sepsis-related mortality rate of up to 50% for untreated neonates, the problem of sepsis is significantly more prevalent in poor nations than in industrialised ones. Neonatal sepsis is a clinical illness that affects infants younger than 28 days of age and is characterised by a variety of generalised, non-specific systemic symptoms [3]. Therefore, this study was conducted to determine the frequency of resistance to 3rd generation cephalosporin in neonates with septicemia at a tertiary care hospital. Materials and Methods: A cross-sectional study was conducted at the NICU of the Aga Khan University Hospital Karachi and nursery departments of the four affiliated secondary care Hospitals from December 2020 to December 2021. We included 477 neonates with sepsis aged 0 to 28 days of life using the non-probability consecutive sampling method. Data were analysed in SPSS version 23.0. All categorical variables were presented as frequencies with percentages, and continuous variables (were presented as mean ±SE. Poststratification applies in gchi-squaretest taken p-value less than equal to 0.05 taken as significant. Results: A total of 377 patients were enrolled. Majority of the patients were preterm neonates, and 70% of the bacterial isolates were resistant to cefotaxime or ceftazidime. 36(9.5%) neonates had bradycardia, 301(79.8%) of neonates had tachycardia, 294 (78%) of neonates had tachypnea, 153 (40.6%) of neonatal sepsis suffered from hypothermia, and 121 (32.1%) of neonatal sepsis patients had a depressed TLC count. Conclusions: We conclude that frequent use of cephalosporin antibiotics has evolved into a high resistance burden. We need local guidelines for the empiric use of antibiotics to cut down the use of cephalosporin, infection control policies to break the chain of infection transmission. Keywords: Neonatal Sepsis, Early-Onset Sepsis, Blood Culture. Cephalosporin Resistance,

Risk Factors Associated with Ventricular Peritoneal Shunt Infections and their Clinical Outcome in Children: A Case-Control Study of the Past 5 Years

Objectives: To determine the risk factors associated with the development of ventricular peritoneal shunt infection and time to infection, as the number of days from most recent shunt intervention to the diagnosis of the infection and clinical outcomes and the antimicrobial susceptibility pattern in children admitted with the ventricular peritoneal shunt. Study Design: Retrospective case-control study Place and duration of study: Aga Khan University Hospital Karachi, Pakistan between January 2015 to December 2020 Results: A total of 460 patients of ages 0-20 years with ventricular peritoneal shunt were selected. Out of 460, 52 individuals met the criteria of the case and were recruited for the study. The findings from multivariable logistic regression, after accounting for potential confounding factors, indicated that the odds of shunt infection were extremely high for patients undergoing surgery in the current admission (adjusted OR 167.3, 95% CI: 8.96 – 3130.86). Likewise, the odds of infection were approximately 12 times more for patients with fever (95% CI: 1.28 – 113.26) and tory of shunt removal (95% CI: 2.06– 67.20). Conclusion: Through a thorough analysis of medical records, the study revealed that several risk factors, such as younger age, previous shunt infections, surgery in current admission, shunt removal/replacement, previous revisions, current complication and fever were associated with a higher risk of shunt infection. Keywords: Risk factors, ventricular peritoneal, shunt infections, clinical outcome,

Female Urinary Incontinence: Frequency, Risk Factors, and Impact on the Quality of Life of Pregnant Pakistani Women.

To determine the frequency and associated risk factors of urinary incontinence (UI), and its effect on the quality of life (QOL) of pregnant Pakistani women. This was a cross-sectional study of 309 pregnant women, 16-40 weeks gestation, age 18- 45 years, at the Aga Khan University Hospital Karachi, between August 2019 and February 2020. Data were obtained using the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short form (ICIQ-UI-SF). The frequency of UI was 63.1%. Stress UI was the commonest type (53.0%) followed by urgency (17.5%) and mixed UI (11.7%). In majority of women, it occurred in small amounts, once a week with a very severe impact on QoL in 24.91% of women, affecting sexual relation the most. Risk factors for UI in pregnancy were age > 35 years (p < 0.02), gestation > 37 weeks (p< 0.00), higher body mass index and family history of UI (p< 0.00), previous instrumental vaginal delivery (P < 0.002), cough, constipation and strenuous job (p< 0.00), and lack of pelvic floor muscle exercises (p <0.03). UI is a common problem in pregnant women in Pakistan. It affects sexual functions the most, with a severe impact on the QOL, however, it commonly remains unreported. Thus the health care providers need to enquire all pregnant women on this issue, especially those at risk, and educate them on the available management options.

Relationship of Abdominal Circumference and Trunk Length With Spinal Anesthesia Block Height in Geriatric Patients Undergoing Transurethral Resection of Prostate.

Spinal anesthesia is commonly used for various surgical procedures. Prediction of spinal anesthesia block height is always a challenging task for anesthetists. Higher than desired levels of spinal anesthesia blocks are associated with serious side effects, while inadequate block height does not provide satisfactory surgical anesthesia. In this study, we observed the relationship between the ratio of trunk length (TL) and square of the abdominal circumference (AC2) and spinal anesthesia sensory block height in geriatric patients undergoing transurethral resection of the prostate (TURP). This is a cross-sectional study conducted at the Aga Khan University Hospital Karachi, Pakistan, on geriatric patients undergoing TURP under spinal anesthesia. Forty-three elderly patients (American Society of Anaesthesiology levelI-III)between 60 and 80 yearswere recruited for the study. In hospital wards, trunk length (TL) and abdominal circumference were recorded before the procedure. In the operating rooms, spinal anesthesia was performed at L3-L4 intervertebral space with 0.5% hyperbaric bupivacaine 10mg (2mls). Block height was measured by the placement of ice pads at different dermatomes. Spearman rank correlation coefficient was used to analyze the physical parameters (TL/AC2) and spinal anesthesia block height. Results: The ratio of trunk length and square of the abdominal circumference (TL/AC2) correlates with spinal anesthesia block height in geriatric patients, where the spearman rank correlation coefficient was r =-0.284 with p = 0.015. The ratio of the long axis (TL) and transection area of the abdomen (AC2), which coincides with (TL/AC2), correlated with spinal anesthesia sensory block height. Hence, elderly patients with a low TL/AC2ratio will have higher block height after spinal anesthesia.

Prevalence of depression in caregivers of stroke patients in Karachi, Pakistan

OBJECTIVES&#x0D; To determine the frequency of depression in caregivers of stroke patients at a tertiary care teaching hospital in Karachi Pakistan.&#x0D; METHODS &#x0D; A cross-sectional study was conducted among caregivers of stroke, who were recruited from the Aga Khan University Hospital Karachi Pakistan, between January 2018 to October 2018. Data was collected through the Urdu Hamilton rating scale for depression (HAM-D-U) and it was analyzed using descriptive and inferential statistics.&#x0D; RESULTS&#x0D; A total of 136 caregivers participated in the study. Among them, 44.1 % were male and 55.9% were female. The mean age of caregivers was 45.38 ± 10.33 years. Using the HAM-D-U scale, depression was present in 64 (47.1%) caregivers. Out of them (n=64), 46 (33.8%) caregivers had mild depression whereas 18 (13.2%) had moderate depression. Depression was found to have a significant relationship with the age of the patient (p=0.002), education level of caregiver (p= 0.012), employment status of caregiver (p=0.012), being a sole caregiver (p=0.039), and monthly family income (p=0.016).&#x0D; CONCLUSIONS&#x0D; Caring for patients with neurological disorders is highly challenging and demanding. The need for this role may arise unexpectedly in one’s life; leaving little space for adjustment and coping. Depression itself can be very paralyzing for the sufferer especially if moderate to severe in intensity. Depression in stroke caregivers can be missed as patients are the center of a clinical visit. Hence, strategies should be designed and reinforced to screen patients and caregivers for depression along with a pathway for an easy and timely referral.

Evaluation of pharmaceutically compounded oral caffeine on the impact of medication adherence and risk of readmission among preterm neonates: A single-center quasi-experimental study.

Caffeine is available in an ampoule, used via parenteral and enteral routes in preterm neonates to treat apnea of prematurity (AOP) in neonates of gestational age ≥ 35-40 weeks. A longer duration of therapy has a higher risk of medication non-adherence due to higher costs and inappropriate dosage forms. Pharmaceutically compounded oral caffeine (PCC) could be an appropriate alternate dosage form. The researchers aimed to determine the impact of PCC on medication-related factors influencing medication adherence (MA) and the frequency of hospital readmission with apnea (HRA) in preterm neonates. We conducted a single-center quasi-experimental study for this quality improvement project using PCC among the preterm neonates admitted in a tertiary care level-III NICU at the Aga Khan University Hospital Karachi, Pakistan, received caffeine therapy, and survived at discharge. The researchers compared pre-PCC data (April-December 2017) with post-PCC data (April-Dec 2018) each for nine months, with three months intervals (January-March 2018) of PCC formulation and implementation phase. The study was conducted according to the SQUIRE2.0 guidelines. The Data were collated on factors influencing MA, including the cost of therapy, medication refill rates, and parental complaints as primary outcome measures. The Risk factors of HRA were included as secondary outcomes. After PCC implementation cost of therapy was reduced significantly from Rs. 97000.0 (729.0 USD) to Rs. 24500.0 (185.0 USD) (p&lt;0.001), significantly higher (p&lt;0.001) number of patients completed remaining refills (77.6% pre-phase vs 97.5% post-phase). The number of parental complaints about cost, ampoule usage, medication drawing issue, wastage, inappropriate dosage form, and longer duration of therapy reduced significantly in post-phase. HRA reduced from 25% to 6.6% (p&lt;0.001). Post-implementation of PCC (RR 0.14; 95% CI: 0.07-0.27) was a significant independent risk factor for reducing HRA using a multivariate analysis model. Longer duration of caffeine therapy after discharge (RR 1.05; 95% CI: 1.04-1.04), those who were born in multiple births (RR 1.15; 95% CI: 1.15-1.15), and those who had higher number of siblings were other significant independent risk factors for HRA. PCC dispensation in the appropriate dosage form at discharge effectively reduced cost, non-adherence to therapy, and risk of hospital readmissions. This neonatal clinical and compounding pharmacist-led model can be replicated in other resource-limiting setting.

Surgical and Oncological Outcomes of Hepatic Resection for Hepatocellular Carcinoma: Report from a Low Volume Centre in a Developing Country

To review the surgical and oncological outcomes of patients who underwent hepatic resection for hepatocellular carcinoma (HCC). Cohort study. Department of Surgery of the Aga Khan University Hospital Karachi, from 2008 to 2019. Consecutive patients who underwent hepatic resection for HCC at the Hospital were included. The data were collected and analysed on aspects including demographics, liver function status, tumour characteristics, perioperative management, and surgical and oncological outcomes. Survival analyses were performed using the Kaplan-Meier method, and log-rank test was applied to determine the influence of variables on overall and disease-free survival. A total of 59 patients underwent hepatic resection for HCC during the study period including 38(64%) males. The majority of the patients had a single lesion (88%), unilobar disease (95%), underlying cirrhosis (75%) and BCLC stage B (73%). Major hepatic resection was performed in 27(46%) patients. The mean duration of surgery was 288+101 minutes and the mean estimated blood loss was 986+637 mls. Postoperative complications developed in 22(37%) patients including surgical complications in 11(19%), liver decompensation in 4(7%) and systemic complications in 9(15%) patients. The overall 30-day mortality was 7%. With a mean follow-up of 2.8 years, disease recurrence was documented in 25(42%) patients and the median overall survival was 45 months. Hepatic resection for HCC is an effective treatment option in this setup. Despite low volumes, surgical and oncological outcomes of hepatic resection for HCC were comparable to the international standards. Hepatocellular carcinoma, Liver resection, Cirrhosis.

Field evaluation of typhoid conjugate vaccine in a catch-up campaign among children aged 9 months to 15 years in Sindh, Pakistan

BackgroundTyphoid conjugate vaccine (TCV) has recently been introduced in the expanded program for immunization (EPI) in Pakistan. Before its introduction in routine immunization, a onetime catchup campaign among children 9 months to 15 years old was conducted in November 2019. We performed field evaluation of TCV against culture confirmed Salmonella Typhi (S. Typhi) among 9 months to 15 years old children during the catch up campaign in Karachi and Hyderabad. MethodsA rapid assessment of blood culture confirmed S. Typhi was performed. Age eligible cases of culture confirmed S. Typhi were identified from the laboratory networks of Aga Khan University Hospital Karachi and Hyderabad, Kharadar General Hospital Karachi, and Liaqat University of Medical & Health Sciences (LUMHS) Hyderabad. Information on sociodemographic, typhoid vaccination history and antimicrobial resistance was collected using a structured questionnaire.Patient medical records and lab reports were also reviewed to collect information on diagnosis and antimicrobial susceptibility information. Information about the population vaccination coverage during catch-up campaign was obtained from the provincial EPI office. Field performance of TCV in catchup campaign was measured by calculating the effectiveness using rapid screening method which is less resource-intensive technique of calculating vaccine effectiveness (VE). ResultsOverall, 968 culture confirmed typhoid cases were enrolled. Among them, 82% (793/968) were from Karachi and 18% (175/968) from Hyderabad. The average age of the participants was 5.68 years, and 54% (523/968) were male. 6% (62/968) of the culture confirmed S. Typhi cases were multidrug resistant (MDR), and 61% (586/968) were extensively drug resistant (XDR). The VE using the TCV coverage data provided by EPI was 98%. ConclusionTCV is effective against culture confirmed S. Typhi among children aged 9 months to 15 years in the catch-up campaign setting. While typhoid vaccination can significantly decrease the burden of typhoid disease, improvements in sanitation and hygiene are necessary for the prevention of spread of enteric fever. Longer term follow up will be needed to assess the duration of protection and requirement for booster doses of TCV.

Choice of Needle in Spinal Anesthesia among Anesthesiologists in Teaching Hospitals of Sindh

Aim: To determine frequency of anesthesiologists practicing pencil- point spinal needles in teaching hospitals of Sindh, Pakistan. Study design: Cross-sectional study. Place and Duration of Study: The Indus Hospital, Aga Khan University Hospital Karachi, Liaquat National Hospital Karachi, Civil Hospital Karachi, Jinnah Postgraduate Medical Centre (JPMC) Karachi, Sindh institute of Urology &amp; Transplantation (SIUT) Karachi, Abbasi Shaheed Hospital Karachi, Ziauddin Hospital Karachi, PNS Shifa Hospital Karachi, Civil Hospital Hyderabad, Chandka Medical College Larkana and Peoples Medical College Nawabshah from 1stJune 2018 to 30thApril 2019. Methodology: Sixty FCPS anesthesiologists or equivalent working in teaching hospitals of Sindh for more than one year, either gender and age 30-70 years were enrolled in the study. MCPS specialists were excluded. Results: Majority anesthesiologists were males 48 (80%). The median working experience was 15 years (IQR): (10-21) with no significant difference between both the genders (mean: 17.2 vs 13.8, p=0.277). Thirty three (55.5%) had professional experience of ≥15 years. Approximately 42% belonged to Aga Khan University hospital. All participants had work experience of general surgery, while 54(90%) worked in Urology, 53(88.3%) participants had experience of Orthopedics, Gynecology and Obstetrics. Conclusion: Although majority of consultants use 25G Pencil Point Needles for spinal anesthesia but still we need to educate more practitioner of government institutes to use smaller gauge spinal needles and the reason of using smaller gauge pencil point needles should be to prevent the chances of PDPH. Key words: Choice, Needle, Spinal anesthesia, Teaching hospitals

Diagnostic accuracy of point-of-care ultrasound compared to standard-of-care methods for endotracheal tube placement in neonates.

Point-of-care ultrasound (POCUS) is a valuable tool to determine endotracheal tube (ETT) placement; however, few studies have compared it with standard confirmation methods. We evaluated the diagnostic accuracy of POCUS and time-to-interpretation for correct identification of tracheal versus esophageal intubations compared to a composite of standard-of-care methods in neonates. A cross-sectional study was conducted in the Neonatal Intensive Care Unit (NICU) at Aga Khan University Hospital Karachi, Pakistan. All required intubations were performed as per NICU guidelines. The clinical team simultaneously determined the ETT placement using standard-of-care methods (auscultation, colorimetric capnography, and chest X-ray) by POCUS. In addition, the clinical team was blinded to the POCUS images. Timings were recorded for each method by independent study staff. A total of 348 neonates were enrolled in the study. More than half (58%) of intubations were in an emergency scenario. POCUS user interpretation showed 100% sensitivity and 94% specificity using an expert as the reference standard. We found a 99.4% agreement (Kappa: 0.96; p < 0.001). Diagnostic accuracy of POCUS compared with at least two standard-of-care methods demonstrated 99.7% sensitivity, 91% specificity, and 98.9% agreement (Kappa:0.93; p < 0.001). The median time required for POCUS interpretation was 3.0 (interquartile range [IQR] 3.0-4.0) seconds for tracheal intubation. The time recorded for auscultation and capnography was 6.0 (IQR 5.0-7.0) and 3.0 (IQR 3.0-4.0), respectively. POCUS is a rapid and reliable method of identifying ETT placement in neonates. Early and correct identification of airway management is critical to save lives and prevent mortality and morbidity.

Effective utilization of time for non-operating room anaesthesia services at Aga Khan University Hospital Karachi: A prospective quality improvement audit.

To identify service quality gaps by reviewing out-of-operating-room anaesthesia services in a tertiary care hospital. This quality improvement audit was conducted at The Aga Khan University Hospital Karachi from July to September 2019, and comprised procedures conducted outside the operating room under anaesthesia and sedation from 8am to 5pm. A data collection form was designed to collect information related to the non-operating-room anaesthesia services. Data was analysed using SPSS Version 19. A total of 123 radiological procedures were observed in 48 working days and endoscopic/radio-therapeutic procedures observed were 98 over 31 days. The mean anaesthesia coverage time was 2.96±1.71 hours per day for radiological procedures, and 2.59±1.07 hours for endoscopic/radio-therapeutic procedures, indicating underutlisation of resources both human and material. A multideciplinary team consisting of all stakeholders should be developed to facilitate the patients and enhance healthcare quality.

Perinatal Stroke; Risk Factors and Outcome. A Study from Aga Khan University Hospital Karachi

Objective: To determine the frequency, risk factors and the outcomes of a perinatal stroke.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Neonatal Intensive Care Unit, Department of Pediatrics, Aga Khan University Hospital, Karachi Pakistan, from Jan to Dec 2019.&#x0D; Methodology: Neonates with perinatal stroke confirmed on the neuroimaging, were included in the study. The primary outcomes were risk factors, divided into 3 groups, maternal, placental and neonatal. The secondary outcome was the condition at the time of the discharge.&#x0D; Results: A total of 58 patients were included in the study. Maternal risk factors identified in the study, were intrauterine infections 10 (17.2%), anti-phospholipid syndrome, gestational diabetes 8 (13.8%) and preeclampsia 7 (12.1%). Chorioamnionitis 9 (15.5%), antepartum hemorrhage 6 (10.3%), and placenta previa 4 (6.9%) were the placental risk factors. Neonatal risk factors were birth asphyxia 35 (60.3%), sepsis/meningitis 8 (13.8%), premature birth 6 (10.3%) and fetal bradycardia 4 (6.9%). Resuscitation was needed in 35 (60.3%) neonates with birth asphyxia. Haemorrhagic stroke was observed in 38 (65.5%) cases, ischemic stroke in 14 (24.1%) cases and mixed type of stroke was found in 6 (10.3%) patients. The total mortality rate in our study was13.8%.&#x0D; Conclusion: Haemorrhagic stroke was more common than ischemic or mixed stroke among the patients of perinatal stroke at our healthcare facility. Patients with low APGAR score at 5 minutes, birth asphyxia and male gender, were most affected.

Perceptions, challenges and experiences of frontline healthcare providers in Emergency Departments regarding Workplace Violence during the COVID-19 pandemic: A protocol for an exploratory qualitative study from an LMIC

IntroductionWorkplace violence (WPV) against Healthcare Workers (HCWs) has emerged as a global issue. Emergency Department (ED) HCWs as front liners are more vulnerable to it due to the nature of...

Practices of vitamin D supplementation leading to vitamin D toxicity: Experience from a Low-Middle Income Country

IntroductionThe trend of prescribing VD preparations for nonspecific body aches and self-medication has increased significantly. The importance of vitamin D toxicity (VDT) has been underestimated and under recognized. This study was done to determine the frequency toxicity (>150 ng/ml) in subjects for 25-hydroxyvitamin D (25OHD) and evaluate the vitamin D (VD) supplements used by these subjects. MethodologyThis descriptive cross-sectional study was conducted at the Section of Chemical Pathology, Aga Khan University Hospital Karachi from April 2020 to March 2021. Subjects with 25OHD toxicity were contacted and information related to history of calcium and VD supplementation were collected. The statistical analysis was performed using the Microsoft Excel 2016. ResultsOver a year period 105398 subjects were tested for serum 25OHD, of which 0.34% (n = 364) subjects had 25OHD level of >150 ng/ml. After satisfying exclusion criteria 186 subjects (78 were <18 years of age and 108 were adults) were included in final analysis. All of these were using VD supplements and the main indications were delayed growth/short height (43.7%, n = 34) and aches or pains in (54.6%, n = 59) in pediatric and adult subjects respectively.Most of the subjects were taking supplements orally (74.1%, n = 138). Commonly prescribed preparation in adults and pediatric was 200,000 IU (70.4%, n = 76) and 400 IU (35.9%, n = 28) respectively. Most subjects took supplements for 1–3 months (68.3%, n = 127). Stated total supplementation ranged from 20,000 IU to 3600,000 IU in pediatric subjects and 200,000 IU to 96,00,000 IU in adults. ConclusionsSupplementation is a leading cause of potential toxic levels of 25OHD. The condition can be prevented by careful use of VD supplements and consistent monitoring.

SNAPPE II Score as a Predictor of Neonatal Mortality in NICU at a Tertiary Care Hospital in Pakistan.

IntroductionThe concept of illness severity scoring has been around for long and is currently being utilized in many neonatal intensive care unit (NICU). Scoring systems that help to quantify mortality risks on the basis of clinical conditions not only help in estimating prognosis, but also help clinicians in making decisions particularly in situations presenting with dilemmas. This study aims to determine SNAPPE-II (Score for Neonatal Acute Physiology-Perinatal Extension) score as a predictor of neonatal mortality in NICU at a tertiary care hospital in Pakistan.MethodologyIt was a longitudinal cohort study. The study was conducted at a neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH) Karachi, Pakistan. All neonates were included who were born in AKUH and who needed respiratory support in NICU.ResultsA total of 333 newborns were enrolled for this study. Out of those 30 (9.1%) neonates expired while 298 (90.9%) survived. Area Under the Receiver operative curve was calculated to obtain the SNAPPE-II score’s diagnostic discrimination ability. Area under the curve (AUC) was 80.2±4.6% which corresponds to a moderate diagnostic accuracy for the prediction of neonatal mortality. The 95% CI for this was between 71.1-89.2%. SNAPPE-II category III (>40) was found to be the strongest predictor of mortality, with a sensitivity of 40% and a specificity of 98.7%.ConclusionThe SNAPPE-II scoring system, we conclude, might be a valuable technique for predicting newborn death in resource-constrained NICUs.

EP.TH.531Occult breast cancer: Breast conservation or Mastectomy in terms of recurrence. A single center experience

Abstract Aim We sought to compare breast conservation therapy &amp; mastectomy as treatment of occult breast cancer in terms of recurrence. Methods It is a retrospective cross sectional study conducted on patients diagnosed to have occult breast cancer and going for either breast conservation therapy or mastectomy at The Aga Khan University Hospital Karachi between January 200o to December 2018, patients will be divided into two groups, first group will be consisting of patients who underwent breast conservation therapy and 2nd one will be of patients who had mastectomy. Patients will be included by consecutive sampling technique. Hospital database will be used to identify patients and data collected on a self designed tool using files and electronic patient records. Patients in both groups will be followed to see local recurrence from date of diagnosis to 2 years post operatively in hospital data base and their files, and then their data will be compared with the reference studies reported in this article. Results Awaited as the study is ongoing. Conclusions Awaited as study is ongoing.