Morbidity and mortality meetings; a new digital portal to enhance learning and objectivity

Morbidity and mortality meetings have long been part of surgical education and practice. They have undergone several modifications over time to include improvement in patient safety and outcomes as an essential utility of conducting morbidity and mortality meetings. Time and again, it has been proposed in literature that standardisation of case discussion results in the efficiency of these meetings. Learning opportunities can be compiled for system improvement. The current review article was planned to present a newly implemented digital morbidity and mortality portal at the Aga Khan University Hospital (AKUH), Karachi, aiming at homogenising the discussion and to add objectivity to the outcome. It is believed that this uniform system across all surgical specialties may play a significant role in enhancing surgical trainees\u27 learning experience

A multidisciplinary approach to triage patients with breast disease during the COVID-19 pandemic: Experience from a tertiary care center in the developing world

Background: The COVID-19 pandemic has created a need to prioritize care because of limitation of resources. Owing to the heterogeneity and high prevalence of breast cancers, the need to prioritize care in this vulnerable population is essential. While various medical societies have published recommendations to manage breast disease during the COVID-19 pandemic, most are focused on the Western world and do not necessarily address the challenges of a resource-limited setting.Aim: In this article, we describe our institutional approach for prioritizing care for patients presenting with breast disease.Methods and results: The breast disease management guidelines were developed and approved with the expertise of the Multidisciplinary Breast Program Leadership Committee (BPLC) of the Aga Khan University, Karachi, Pakistan. These guidelines were inspired, adapted, and modified keeping in view the needs of our resource-limited healthcare system. These recommendations are also congruent with the ethical guidelines developed by the Center of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (SIUT), Karachi. Our institutional recommendations outline a framework to triage patients based on the urgency of care, scheduling conflicts, and tumor board recommendations, optimizing healthcare workers\u27 schedules, operating room reallocation, and protocols. We also describe the Virtual Blended Clinics , a resource-friendly means of conducting virtual clinics and a comprehensive plan for transitioning back into the post-COVID routine.Conclusion: Our institutional experience may be considered as a guide during the COVID-19 pandemic, particularly for triaging care in a resource-limited setting; however, these are not meant to be universally applicable, and individual cases must be tailored based on physicians\u27 clinical judgment to provide the best quality care

Adverse events monitoring: A step towards making AKUH a safe place for patients

Background: Medical harm and errors are almost inevitable outcomes of failures in processes of care. Therefore by focusing on the adverse events experienced by patients, a hospital can foster a culture of safety that aims at reducing them. . AKUH since years has quantified adverse events using conventional voluntary incident reporting. Research has concluded that only 10-20% of total errors in the hospital are ever reported. Thus one such initiative has been taken by The Aga Khan University Hospital, Karachi, from January 2011. IHI’s (Institute of Healthcare Improvement) global trigger tools (GTT) is utilized to calculate hospital’s harm rate. The purpose of using IHI’s GTT was to identify number of adverse events in hospital, categorize them according to severity of harm, establish strategies to reduce harm rate and compare with our own trends to improve it over time. Methods: A cross-sectional retrospective review was done from January to December 2011 using standard IHI’s GTT trigger tools. Random sample of 20 closed medical records per month were reviewed and audited by a patient safety nurse first then a clinician, against ‘56’ triggers mentioned GTT tool. Patients who were shifted to high dependency area during the hospital stay were selected. Results: Total 240 records reviewed in the year 2011 in which 66 (27.5%) patients experienced an adverse event with an average of 1.45 AE per patient; totaling the AEs to 96 in 66 patients. About 64 (66.6%) AEs contributed to temporary harm to patient requiring intervention (Category E), while 22 (22.9%) required prolong hospitalization (Category F), 04 (4%) lead to permanent harm (Category G), about 05 (5.2%) required intervention to sustain life (Category H) and 01 (1%) led to patient’s death (Category I). On the basis of these results, improvement plan were developed by respective multidisciplinary team with the goal to improve patient safety. Conclusions: These results suggest that adverse events are definitive source of harm to the patient. Using GTT has aided to identify those events which were not voluntarily reported. Hence the hospital plans to continue using this promising tool to identify AEs proactively

Surgical management during the COVID-19 era at a private tertiary care hospital of Karachi, Pakistan: A cross-sectional study

Background: The coronavirus disease 2019 (COVID-19), declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery.Methodology: This is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher’s exact test. A p-value of \u3c0.05 was considered significant.Results: A total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74 (4.2%) of the COVID-19-positive patients underwent emergency surgeries.Conclusions: The timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries

A Classification Based Framework to Predict Viral Threads

Online social media allows consumers to engage with each other and to create, share, discuss and modify user-generated content in a highly interactive way. Social media platforms have therefore become critical for companies trying to gauge the pulse of consumers, help identify issues faster, receive immediate feedback on products and offering etc. An effective social media strategy therefore requires companies to mine large volumes of structured unstructured and semi-structured online textual data in order to gain insights into the underlying traits of the consumers and prevailing public opinion. These insights can provide opportunities for market research, protection of brand reputation and a mechanism to gauge user preferences in an attempt to maximize customer satisfaction and consumer-brand engagement. In this paper, we propose and evaluate a classification based framework to predict thread lengths in online discussion forums in order to identify potential topics that may of interest to a particular online community. We identify and evaluate several key features of viral social media conversations through extensive experiments conducted on health 2.0 datasets. We also present a pharmaceutical industry based case study to illustrate how well the viral thread topics relate to real world events

Cultural barriers for women in surgery: How thick is the glass ceiling? An analysis from a low middle-income country

Background: This study aimed to highlight cultural barriers faced by surgeons pursuing a surgical career faced by surgeons at a tertiary care hospital in Pakistan. As more females opt for a surgical career, barriers faced by female surgeons are becoming increasingly evident, many of which are rooted in cultural norms. In Pakistan, a predominantly Muslim-majority, low middle-income country, certain societal expectations add additionally complexity and challenges to existing cultural barriers.Methods: A cross-sectional survey was administered via e-mail to the full-time faculty and trainees in the Department of Surgery at the Aga Khan University Hospital, Karachi, Pakistan, from July 2019 to November 2019.Results: In total, 100 participants were included in this study, with the majority being residents (55.6%) and consultants (33.3%). 71.9% of female surgeons felt that cultural barriers towards a surgical career existed for their gender, as compared to 25.4% of male surgeons (p \u3c 0.001). 40.6% of females reported having been discouraged by family/close friends from pursuing surgery, as compared to only 9.0% of males (p \u3c 0.001). Moreover, a greater percentage of females surgeons were responsible for household cooking, cleaning and laundry, as compared to male surgeons (all p \u3c 0.001). Lastly, 71.4% of female surgeons felt that having children had hindered their surgical career, as compared to 4.8% of males (p \u3c 0001).Conclusion: Our study shows that significant cultural barriers exist for females pursuing a surgical career in our setting. Findings such as these emphasize the need for policy makers to work towards overcoming cultural barriers

Dynamics of IgG antibody responses to SARS-CoV-2 reveals insight into immunity during the early pandemic period in Pakistan

Background: COVID-19 related disease morbidity and mortality has varied worldwide. We investigated antibody and T cell responses to SARS-CoV-2 in COVID-19 cases and exposed but healthy individuals further compared with pre-pandemic controls in a high infectious disease burden setting.Methods: IgG antibodies against Spike and Spike Receptor Binding Domain (RBD) were determined by ELISA in a Health Care cohort (HC; n=304), COVID-19 cases (n=163) and Pre-Pandemic Controls (PPC; n=114). Neutralizing antibody assays and T cell ELISpot assays were also conducted.Findings: IgG anti Spike proteins and RBD were present in all three groups albeit at varying levels. The highest rate of positivity was observed in COVID-19 cases (87.7% to Spike; 53.9% to RBD); followed by HC (35% to Spike; 21.3% to RBD) and PPC (12.2% to Spike; 10.50% to RBD). Antibody positivity in HC rose from 4.5% in October 2020 to 61% in January 2021. Levels of IgG antibodies to Spike and RBD strongly correlated in COVID-19 and HC but not in PPC. IgG to RBD was associated with neutralizing activity against SARS-CoV-2. Spike reactive T cells were identified in COVID-19 patients (6/18), HC (2/7) and but only one PPC (1/6).Interpretation: IgG to Spike and RBD in pre-pandemic sera is likely associated with cross-protection induced by other pathogens. The increasing percentage of IgG antibody positivity in HCC over the pandemic period may be due to expansion of cross-reactive B cells as observed in PPC, due either to exposure or asymptomatic subclinical infection with SARS-CoV-2. Neutralizing activity of RBD IgG antibodies and reactive T cells to Spike in PPC suggests the presence of memory B and T cells to cross-reactive epitopes that can expand quickly, jumpstarting protection against SARS-CoV-2.Funding Information: This work was supported by the Provost’s Academic Priorities Fund, Aga Khan University. Funding support was also received through Swedish Research Council project SRL 4-182/2019. We acknowledge the support for recombinant protein provided by IBET, NOVA University, Portugal. MV was supported by the European Union H2020 ERA project (No 667824 – EXCELLtoINNOV). Declaration of Interests: The authors have no competing interests to declareEthics Approval Statement: This study was approved by the Ethical Review Committee of The Aga Khan University (projects #2020-5152-11688 and 2020-3687-10181)

Humoral and T cell responses to SARS-CoV-2 reveal insights into immunity during the early pandemic period in Pakistan

Background: Protection against SARS-CoV-2 is mediated by humoral and T cell responses. Pakistan faced relatively low morbidity and mortality from COVID-19 through the pandemic. To examine the role of prior immunity in the population, we studied IgG antibody response levels, virus neutralizing activity and T cell reactivity to Spike protein in a healthy control group (HG) as compared with COVID-19 cases and individuals from the pre-pandemic period (PP).Methods: HG and COVID-19 participants were recruited between October 2020 and May 2021. Pre-pandemic sera was collected before 2018. IgG antibodies against Spike and its Receptor Binding Domain (RBD) were determined by ELISA. Virus neutralization activity was determined using a PCR-based micro-neutralization assay. T cell - IFN-γ activation was assessed by ELISpot.Results: Overall, the magnitude of anti-Spike IgG antibody levels as well as seropositivity was greatest in COVID-19 cases (90%) as compared with HG (39.8%) and PP (12.2%). During the study period, Pakistan experienced three COVID-19 waves. We observed that IgG seropositivity to Spike in HG increased from 10.3 to 83.5% during the study, whilst seropositivity to RBD increased from 7.5 to 33.3%. IgG antibodies to Spike and RBD were correlated positively in all three study groups. Virus neutralizing activity was identified in sera of COVID-19, HG and PP. Spike reactive T cells were present in COVID-19, HG and PP groups. Individuals with reactive T cells included those with and without IgG antibodies to Spike.Conclusions: Antibody and T cell responses to Spike protein in individuals from the pre-pandemic period suggest prior immunity against SARS-CoV-2, most likely from cross-reactive responses. The rising seroprevalence observed in healthy individuals through the pandemic without known COVID-19 may be due to the activation of adaptive immunity from cross-reactive memory B and T cells. This may explain the more favourable COVID-19 outcomes observed in this population