Resection of posterior mediastinal tumors by video assisted thoracic surgery

Abstract This case report illustrates successful Video Assisted Thoracic Surgery (VATS) performed on a 45-year-old woman and 52-year-old man presenting with a mass in left and right paravertebral space on the CT scan respectively. VATS has many benefits over traditional open operation (thoracotomy), resulting in less pain and shorten recovery time. However, VATS has higher equipment cost but when an experienced surgeon performs the surgery, better outcomes are achieved. VATS is not common in Pakistan\u27s surgical setup as it is an expensive method of eradicating mediastinal pathologies and not every patient undergoes VATS. The primary objective of presenting these cases is to promote the use of VATS specifically for removal of posterior mediastinal tumors and improve the surgical outcomes

Prevalence of body-focused repetitive behaviors in three large medical colleges of Karachi: a cross-sectional study.

Background: Body-focused repetitive behaviors (BFRBs) that include skin picking (dermatillomania), hair pulling (trichotillomania) and nail biting (onychophagia), lead to harmful physical and psychological sequelae. The objective was to determine the prevalence of BFRBs among students attending three large medical colleges of Karachi. It is imperative to come up with frequency to design strategies to decrease the burden and adverse effects associated with BFRBs among medical students. Methods: A cross-sectional study was conducted among 210 students attending Aga Khan University, Dow Medical College and Sind Medical College, Karachi, in equal proportion. Data were collected using a pre tested tool, “Habit Questionnaire”. Diagnoses were made on the criteria that a student must be involved in an activity 5 times or more per day for 4 weeks or more. Convenience sampling was done to recruit the participants aged 18 years and above after getting written informed consent. Results: The overall prevalence of BFRBs was found to be 46 (22%). For those positive for BFRBs, gender distribution was as follows: females 29 (13.9%) and males 17 (8.1%). Among these students, 19 (9.0%) were engaged in dermatillomania, 28 (13.3%) in trichotillomania and 13 (6.2%) in onychophagia. Conclusions: High proportions of BFRBs are reported among medical students of Karachi. Key health messages and interventions to reduce stress and anxiety among students may help in curtailing the burden of this disease which has serious adverse consequences

Successful tricuspid valvectomy in a septic patient with tricuspid valve endocarditis

Abstract Endocarditis is characterized by vegetations, which is a mass of platelets, fibrin, micro-colonies of micro-organisms, and inflammatory cells, in the endocardium. Over the past three decades, the incidence of right-sided endocarditis has risen dramatically in Pakistan. We report a 36-year woman with a history of repeated intravenous analgesic injections for low back pain, presenting with high grade fever, sepsis and a white cell count of 44,000 with 90% neutrophils. Echocardiography showed large mobile vegetations on TricuspidValve (TV). Tricuspid Valve Endocarditis (TVE) is generally responsive to medical treatment; however, about 25% of TVE patients require surgical intervention. Long-term survival of a patient is possible without a prosthetic TV replacement, particularly if the pulmonary artery pressure is normal

Peri-operative determinants of prolonged CICU stay after coronary artery bypass graft surgery in elderly at a private tertiary care hospital: a case control study

Abstract OBJECTIVE: To explore peri-operative risk factors associated with prolonged stay in cardiac intensive care unit among patients undergoing isolated coronary artery bypass grafting. METHODS: This retrospective case control study was conducted at the Aga Khan University Hospital, Karachi, comprised medical records of patients who had undergone cardiothoracic revascularisation surgery from January 2006 to December 2013. The patients were grouped into cases and controls at a ratio of 1:2 on the basis of length of stay at cardiac intensive care unit, i.e. \u3e72 hours andanalysis. RESULTS: Of the 999 patients, 333(33.3%) were cases and 666(66.6%) were controls. The mean age of cases was 62.5±9.7 years and that of controls was 60.8±9.6 years (p=0.007). The number of males was 280(84.1%) among the cases and 489(73.4%)among the controls. Adjusted odds ratio and 95% confidence interval for age and male gender were 1.02 (1.0,1.03) and [1.90 (1.32,2.74)]; diabetics were at high risk of staying longer [1.51 (1.13,2.02)]; previous cardiovascular interventions [1.65 (1.05,2.59)], intra-aortic balloon pump insertion [1.45 (1.01,2.08)], initial ventilation time and post-operative bleeding tamponade were independently associated with prolonged cardiac intensive care unit stay [1.01 (1.00, 1.01)] and [1.9 (1.13,3.2)], respectively. The risk of dying among the cases was three times more after adjusting for all covariates in the model [3.1 (1.52,6.31)]. CONCLUSION: Advanced age, male gender, diabetes, previous cardiovascular interventions, post-operative intra-aortic balloon pump insertion, initial ventilation support and post-op bleeding tamponade were found to be the independent risk factors for prolonged cardiac intensive care unit stay

Dead on arrival in a low-income country: results from a multicenter study in Pakistan

BACKGROUND: This study assessed the characteristics of dead on arrival (DOA) patients in Pakistan. METHODS: Data about the DOA patients were extracted from Pakistan National Emergency Department Surveillance study (Pak-NEDS). This study recruited all ED patients presenting to seven tertiary care hospitals during a four-month period between November 2010 and March 2011. This study included patients who were declared dead-on-arrival by the ED physician. RESULTS: A total of 1,557 DOA patients (7 per 1,000 visits) were included in the Pak-NEDS. Men accounted for two-thirds (64%) of DOA patients. Those aged 20-49 years accounted for about 46% of DOA patients. Nine percent (n = 72) of patients were brought by ambulance, and most patients presented at a public hospital (80%). About 11% of DOA patients had an injury. Factors significantly associated (p \u3c 0.05) with ambulance use were men (adjusted odds ratio [aOR] = 2.72), brought to a private hospital (OR = 2.74), and being injured (aOR = 1.89). Cardiopulmonary resuscitation (CPR) was performed on 6% (n = 42) of patients who received treatment. Those brought to a private hospital were more likely to receive CPR (aOR = 2.81). CONCLUSION: This study noted a higher burden of DOA patients in Pakistan compared to other resourceful settings (about 1 to 2 per 1,000 visits). A large proportion of patients belonging to productive age groups, and the low prevalence of ambulance and CPR use, indicate a need for improving the prehospital care and basic life support training in pakistan

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation