The environment under the knife: A review of current Eco-surgical strategies and recommendations for Pakistan

The healthcare sector at its core is based on the fundamentals belief to do no harm and bring about betterment in the lives of the people. Paradoxically, hospitals are one of the leading contributors to pollution, greenhouse gas (GHG) emissions and toxic waste material worldwide. Surgical care delivery is quite resource intensive, consuming significant amount of energy and equipment as well as producing large quantities of waste. With climate change being a global priority, it is crucial that hospitals re-evaluate the environmental impact of such practices. The current review was planned to identify areas of improvement in surgical care in terms of sustainability, as well as describe efficient and innovative strategies for hospitals in Pakistan to lessen their impact
on the environment.

Implementation and Usefulness of Telemedicine Services in the Healthcare System of Pakistan

Telemedicine, also known as telehealth or e-health, is the remote delivery of healthcare services over the telecommunications infrastructure. It allows healthcare providers to evaluate, diagnose and treat patients without the need for an in-person visit. Pakistan is a developing nation with its population majorly concentrated in rural areas which lack adequate high quality healthcare services and patient care. Telemedicine has the potential to surpass many barriers that hinder the healthcare delivery in these remote and rural areas. However, Pakistan hasn’t been able to achieve significant benefit from these e-health advancements due to lack of adequate guidelines, laws or policies needed for e-health to properly work here and due to a lack of government’s interest. There are many barriers to implementation of e-health in Pakistan with very low literacy rate being the major one. Other barriers include high budget requirements and limited access to internet and technology in remote and rural areas of the country.
Apart from these barriers, there are many challenges that the patients and doctors face dealing with telemedicine. In order to achieve significant benefit from these ehealth technologies in Pakistan, it is also necessary to increase the knowledge of it in both patients and doctors. More workshops and training programs should be arranged to teach doctors about the telemedicine technology and proper telemedicine guidelines should be made and regulated by higher authorities

Sequelae of Infective Endocarditis: Ruptured Aortic Root Abscess in a 38-Year-Old Female With Complicated Infective Endocarditis

A 38-year-old female with no known comorbidities or previous history of heart disease presented to the hospital with a three-day history of drowsiness and shortness of breath. Transthoracic echocardiography was performed, which showed large vegetations on aortic and tricuspid valves. In addition, there was severe aortic regurgitation with a possible abscess on the non-coronary cusp of the aortic valve.

The patient was admitted, and a provisional diagnosis of disseminated tuberculosis, Infective endocarditis (IE), and sepsis was made. Surgical intervention was planned. Intraoperative findings revealed that a fistula had formed connecting the aorta and right atrium, which was closed with an autologous graft derived from the patient’s pericardial tissue. Vegetations were removed, and the aortic valve was replaced with a metallic valve.

This case report presents a patient with complicated IE with a ruptured aortic root abscess. Mechanical complications associated with IE, such as in our case, are rare among patients with IE. However, surgical intervention should be considered as an option in complicated cases of IE when standard therapy fails.

An outcome of emergency vascular surgery performed by General Surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

Objective: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality.

Method: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20.

Results: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8+11.5 years (range: 14-63 years). Mean duration of hospital stay was 11+3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003).

Conclusion: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Effects of Integrating Family Planning With Maternal, Newborn, and Child Health Services on Uptake of Voluntary Modern Contraceptive Methods in Rural Pakistan: Protocol for a Quasi-experimental Study

Background:
The uptake of modern contraceptive methods (MCMs) remains low, with 25% of women reporting their use in Pakistan. The overarching interventions covering service delivery platforms at facility and community levels necessitate the integration of family planning (FP) with maternal, newborn, and child health (MNCH) services.

Objective:
The main aim of this study is to evaluate the impact of an integrated FP-MNCH service delivery model to increase coverage of MCMs in rural Pakistan. Moreover, we aim to measure the level of effectiveness of interventions regarding the uptake of MCMs.

Methods:
A quasi-experimental, sequential, mixed methods study design with pre- and postevaluation will be adopted to evaluate the impact of integration of FP with MNCH services. The interventions include the following: (1) capacity strengthening of health care providers, including technical trainings; training in counseling of women who attend immunization centers, antenatal care (ANC) clinics, and postnatal care (PNC) clinics; and provision of job aids; (2) counseling of women and girls attending ANC, PNC, and pediatric clinics; (3) ensuring sustained provision of supplies and commodities; (4) community engagement, including establishing adolescent-friendly spaces; and (5) use of District Health Information System data in decision-making. Descriptive statistics will be used to estimate prevalence (ie, proportions) and frequencies of outcome indicators. A univariate difference-in-difference analytical approach will be used to estimate the effect of the interventions. In addition, a Blinder-Oaxaca decomposition analysis will be conducted to identify and quantify determinants of the modern contraceptive prevalence rate.

Results:
The intervention phase began in July 2021 and will run until June 2022. The impact assessment will be conducted from July to September 2022.

Conclusions:
This project will evaluate the impact of integrating FP with MNCH services. Furthermore, this study will identify the drivers and barriers in uptake of MCMs and will simultaneously help in modifying the interventional strategies that can be scaled up through existing service delivery platforms within the public and private sectors, according to the local sociocultural and health system context.

Perioperative registries in resource-limited settings: The way forward for Pakistan

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these
into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical records and high lossto- follow-up rates, requiring telemedicine initiatives as an
adjunct to existing care for the assessment of postdischarge outcomes.

The environment under the knife: A review of current Eco-surgical strategies and recommendations for Pakistan

The healthcare sector at its core is based on the fundamentals belief to do no harm and bring about betterment in the lives of the people. Paradoxically, hospitals are one of the leading contributors to pollution, greenhouse gas (GHG) emissions and toxic waste material worldwide. Surgical care delivery is quite resource intensive, consuming significant amount of energy and equipment as well as producing large quantities of waste. With climate change being a global priority, it is crucial that hospitals re-evaluate the environmental impact of such practices. The current review was planned to identify areas of improvement in surgical care in terms of sustainability, as well as describe efficient and innovative strategies for hospitals in Pakistan to lessen their impact on the environment. The implementation of the 5 R’s strategy for surgical care (Reduce, Reuse, Recycle, Rethink and Research) as well as general measures to improve energy efficiency, waste management and inter-sectoral collaboration will provide significant benefits to the environment and advance efforts to creating a more sustainable future for surgical healthcare in Pakistan.

Current perspectives of oncoplastic breast surgery in Pakistan

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income
countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement
distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan.

Analysing the trends in breast surgery practice during COVID-19 pandemic: A comparative study with the Pre-COVID era

The emergence of coronavirus disease 2019 (COVID-19) pandemic has crippled the healthcare systems all over the world. Cancer treatment is indispensable and disruption in its provision can lead to unanticipated consequences. No local data exists that has quantified the impact of COVID-19 pandemic on breast cancer surgery in a lower middle-income country (LMIC), therefore, the present retrospective comparative cohort study is directed to determine the trends in breast surgery operative volumes and its outcomes at our institution in Pakistan.

Materials and methods
Data was collected retrospectively from Pre-COVID-19 and COVID-19 era to determine impact of the current pandemic on breast cancer management practices and outcomes.

Results
Cohort results showed a decline in the number of surgeries during COVID-19 era. A total 149 cases were operated during study period vs. 231 during same Pre-COVID-19 i.e. a 35.5% drop in cancer surgeries. In early COVID-19 time frame, only 4 patients had breast reconstruction, 12 out of 149 (8.05%) surgical candidates were identified having positive COVID-19 status preoperatively and one ASA class 3 patient caught COVID-19 post-surgery and succumbed to virus.

Conclusion
Pandemic has a negative effect on cancer management in a LMIC with compromised access and care of cancer patients.

PakSurg: The first trainee-lead model for multicenter surgical research collaboration in Pakistan

We describe creation and piloting of the PakSurg Collaborative, devised via integration of existing trainee-led collaborative models in the United Kingdom with the resource-limited surgical care in Pakistan. This is the first trainee-lead surgical research collaborative in Pakistan, established by the student-lead Surgery Interest Group from the Aga Khan University. The project involved creation of a model that included a steering committee comprising of five teams which worked in conjunction with collaborators from multiple hospitals. To facilitate this collaboration, a comprehensive and cost-efficient study management pathway was developed. The PakSurg Collaborative has the potential to deliver methodologically robust, high-quality, multicenter surgical evidence from Pakistan. This nationally representative data could inform evidence-based surgical guidelines, potentially translating into improved outcomes for patients undergoing surgery.