Challenges of pediatric anesthesia services and training infrastructure in tertiary care teaching institutions in Pakistan: A perspective from the province of Sindh

Background: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh.Methods: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data.Results: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria.Conclusions: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies

A national survey of critical care services in hospitals accredited for training in a lower-middle income country: Pakistan

Purpose: To describe the extent and variation of critical care services in Pakistan. Materials and methods: A cross-sectional survey was conducted in all intensive care units (ICUs) recognised for postgraduate training to determine administration, infrastructure, equipment, staffing, and training. Results: There were 151 hospitals recognised for training, providing 2166 ICU beds and 1473 ventilators. Regional distribution of ICU beds per 100,000 population ranged from 1.0 in Sindh to none in Gilgit Baltistan (median 0.7). A senior clinician trained in critical care was available in 19 (12.1%) of units. One-to-one nurse-to-bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. Availability of 1:1 nursing also varied between provinces, ranging from 56.5% in Punjab compared to 0% in Azad Jamu Kashmir. Similarly, there was disparity in the availability of ventilators between provinces. All ICUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps). Conclusion: Pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. Investment in critical care training for doctors and nurses is needed

Biosorption of Metals and Metalloids

Industrial activities such as mining operations, refining of ores and combustion of fuel oils play a relevant role in environmental pollution since their wastes contain high concentrations of toxic metals that can add significant contamination to natural water and other water sources if no decontamination is previously applied. As toxic metals and metalloids, including arsenic, cadmium, lead, mercury, thallium, vanadium, among others, are not biodegradable and tend to accumulate in living organisms, it is necessary to treat the contaminated industrial wastewaters prior to their discharge into the water bodies. There are different remediation techniques that have been developed to solve elemental pollution, but biosorption has arisen as a promising clean-up and low-cost biotechnology. Biosorption is one of the pillars of bioremediation and is governed by a variety of mechanisms, including chemical binding, ion exchange,physisorption, precipitation, and oxide-reduction. This involves operations(e.g. biosorbent reuse, immobilization, direct analysis of sample without destruction) that can be designed to minimize or avoid the use or generation of hazardous substances that have a negative impact on the environment and biota, thus following the concepts of "green chemistry" and promoting the environmental care. Furthermore, it has to be specially considered that the design of a biosorption process and the quality of a biosorbent are normally evaluated from the equilibrium, thermodynamic, and kinetic viewpoints.Therefore, a successful biosorption process can be only developed based on multidisciplinary knowledge that includes physical chemistry, biochemistryand technology, among other fields.In this chapter, we explain in detail all the aforementioned aspects. State of the art applications of biosorbents for metals and metalloids removal are carefully revised based on a complete analysis of the literature. Thus, it is evidenced in this chapter that the main points to consider regarding biosorption are the type of biomaterial (e.g. bacteria, fungi, algae, plant?derivatives and agricultural wastes, chitin/chitosan based materials) and the presence of a broad set of functional groups on their surface that are effective for the removal of different toxic metals and metalloids. In fact, removal percentages as high as 70-100% can be found in most works reported in the literature, which is demonstrating the excellent performance obtained with biosorbents. Also, biosorbents have evolved with the help of nanotechnology to modern bio-nano-hybrids materials having superlative sorption properties due to their high surface area coming from the nano-materials structures and multifunctional capacity incorporated from the several types of chemical groups of biomaterials. These, as well as other important aspects linked to biosorption are fully covered in the present chapter.Fil: Escudero, Leticia Belén. Universidad Nacional de Cuyo. Facultad de Ciencias Exactas y Naturales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza; ArgentinaFil: Quintas, Pamela Yanina. Universidad Nacional de Cuyo. Facultad de Ciencias Exactas y Naturales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza; ArgentinaFil: Wuilloud, Rodolfo German. Universidad Nacional de Cuyo. Facultad de Ciencias Exactas y Naturales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza; ArgentinaFil: Dotto, Guilherme L.. Universidade Federal de Santa Maria; Brasi

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status