Role of Primary Caregivers Regarding Unintentional Injury Prevention Among Preschool Children: A Cross-Sectional Survey in Low- and Middle-Income Country

Importance
Unintentional childhood injuries significantly strain healthcare resources, and their preventable measures can significantly reduce morbidity and mortality.

Objectives
To investigate the role of primary caregivers in preventing unintentional injuries and to identify the groups that require special health intervention programs to reduce the burden of this public health concern.

Methodology
A cross-sectional survey was conducted at three hospitals in Karachi, Pakistan. Parents of preschool children who visited pediatric clinics were invited to participate in the study by completing a self-administered questionnaire comprising questions about knowledge, attitudes, and practices towards preventing unintentional injuries among children.

Results
With an 80% response rate, the overall mean knowledge, attitude, and practices (KAP) score was 27.40 ± 3.48. Only 14.3% of the participants had a high KAP score, while 83.6% and 2.1% of the respondents had moderate and low KAP scores, respectively. People of lower socioeconomic status, unemployed, less educated, and families with more than one preschool child were less knowledgeable and non-adherent to unintentional preventive injury. It was found that 21% of the children had suffered from an unintentional severe injury in the past, and the internet was the most frequent source of gaining knowledge among parents.

Conclusion
Parental knowledge, attitude, practices, and adherence to child safety measures are sub-optimal in our cohort of studied participants. Raising awareness and providing the counseling are essential in reducing the burden of unintentional injuries.

Digital health and telemedicine in Pakistan: Improving maternal healthcare

Pakistan has not benefited significantly from telemedicine, despite the promise that it could overcome many of the barriers impeding maternal healthcare delivery in emerging markets. Due to a lack of a regulatory framework and a lack of government interest, new companies in Pakistan have a hard time establishing healthcare projects that will be cost-effective and innovative. A review of telemedicine adoption in the past and present for improving maternal healthcare standards is presented in this article. Furthermore, a discussion of the challenges associated with digital health adoption is provided, as well as possible and feasible policies for making the use of digital health in maternal health more effective.

Breast cancer in a teenage girl with BRCA mutation: A case report from a low middle-income country

Introduction
A staggering majority of pediatric breast masses are benign (mostly fibroadenoma) and so a biopsy is not readily performed as it can potentially lead to a future breast disfigurement. However, this should not be standard practice as this can lead to a delayed diagnosis, and hence, the treatment of pediatric breast cancer (BC); this was also seen in our patient’s scenario.

Case history
Here, we report the case of the youngest known breast cancer patient in Pakistan, a 15-year-old girl. The right-sided breast lump which was diagnosed clinically as a fibroadenoma later turned out to be stage IIb pT3N0M0 metaplastic breast carcinoma with BRCA1 positivity and mutations in SMARCA4. Being young and unmarried, the patient and her family decided to opt for breast-conserving surgery with high-risk surveillance for breast and ovaries.

Discussion
We believe that prophylactic surgeries can be delayed with strict surveillance and thorough counseling. As pediatric BC is linked to a less favorable prognosis, every young patient diagnosed with breast cancer and their family should undergo genetic testing. BC management should be handled by specialists in the field and doctors should be trained for initial diagnostics and timely referral of patients.

Conclusion
It is important to improve our understanding of genetic predisposition and testing in lower-middle-income countries. Considering the changing global trends, we suggest that the utilization of genetic services is direly needed to improve preventative care for at-risk individuals with breast and other cancers.

The Impact of Delayed Surgical Care on Patient Outcomes With Alimentary Tract Perforation: Insight From a Low-Middle Income Country

Introduction
In-patient delay is associated with increased mortality in patients with alimentary tract perforations. Access to surgical care is a glaring health issue in low-middle income countries (LMICs), where patient presentation is also delayed for a myriad of reasons, which can be broadly categorized as social/cultural, financial, and structural in their nature. The impact these delays have on surgical outcomes in low-middle income countries is not known.

Methods
A retrospective cohort study of patients who underwent emergency laparotomy for alimentary tract perforation from July 2015 to June 2018 was conducted at a tertiary care hospital in Karachi, Pakistan. Time was recorded in two variables: symptom onset to emergency room presentation (ERT) and emergency room to operation room time (ORT).

Results
Overall, 80 patients were included in the study. The 12 (15%) patients who expired were significantly older (57 ± 17.7 years of age), had a higher Charlson Comorbidity Index and had longer ORT [median ORT in hours-discharged vs expired: 8.2 (IQR 5-15) vs 16 (IQR 12-28) p=0.02]. ERT was also longer but lacked statistical significance [median ERT in hours-discharged vs expired: 24 (IQR 22-72) vs 48 (IQR 24-120) p=0.19]. Multivariable logistic regression analysis revealed ORT to be significantly associated with mortality [odds ratio (OR): 1.02, 95% confidence interval (CI): 1.003-1.041; p=0.02]. Adjusted Cox regression analysis showed that each hour of ORT increased the risk of mortality by 1.5% [hazard ratio (HR) 1.015, 95% CI 1.001-1.030].

Conclusion
Inpatient delays increased the risk of mortality for patients undergoing emergency laparotomy for alimentary tract perforation. Larger sample sizes and prospective studies are needed to better understand this relationship and the impact pre-hospital delays have on outcomes.

Mortality Rate in Pakistan – among Low and Middle-Income Countries

Age-specific and sex-specific cause of death determination is becoming very important task particularly for low- and middle-income countries (LMICs). Therefore, consistent openly accessible information with reproducibility may have significant role in regulating the major causes of mortality both in premature child and adults. The United Nations (UN) reported that 86% deaths (48 million deaths) out of 56 million globally deaths occurred in the LMICs in 2010. The major dilemma is that most of the deaths do not have a diagnosis of COD in such countries. Despite of the allocation of a large portion of resources to decrease the devastating impacts of chronic illnesses, their prevalence as well as the health and economic consequences remains staggeringly high. There are multiple levels of interventions that can help in bringing about significant and promising improvements in the healthcare system. Currently, Pakistan is facing double burden of malnutrition with record high prevalence rates of chronic diseases. Pakistan spends only a marginal of its GDP (1.2%) versus the recommended 5% by World Health Organization. On average, there are eight hospitals per district, with people load per hospital being 165512.452 and poor data management in the country, and we lack a consistent local registry on all-cause of mortality. This article was planned to compile the data related to major causes and disease specific mortality rates for Pakistan and link these factors to the social-economic determinants of health.

The Impact of COVID-19 on the Psychological Well-Being of Surgeons in Pakistan: A Multicenter Cross-Sectional Study

Introduction
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic left a profound and pervasive impact on the healthcare infrastructure on a global scale. Since its onset, the pattern of reported cases and its associated mortality had shown variability with intermittent peaks causing a significant effect on the psychological well-being of the surgeons of Pakistan. The aim of this study was to assess the effects of the COVID-19 pandemic on the mental well-being of surgeons in Pakistan.

Methods
This multicenter cross-sectional study was carried out to assess the impact of COVID-19 on the psychological well-being of surgeons in Pakistan. The validated Self-Reporting Questionnaire-20 (SRQ-20) tool was circulated electronically via Google Forms (Google, Inc., Mountain View, CA, USA) in the practicing surgical fraternity across all five regions of Pakistan, i.e., Sindh, Punjab, Baluchistan, Khyber Pakhtunkhwa (KPK), and Azad Jammu and Kashmir (AJK).

Results
This study showed that the female gender, having fewer years of working experience, non-satisfaction with the available personal protective equipment (PPE), and working in the public sector were the factors affecting the psychological well-being of surgeons during the pandemic.

Conclusion
Considering the continuous rise in new cases during the ongoing pandemic, the mental health of surgeons working in low- and middle-income countries (LMIC) such as Pakistan has been significantly affected. There is an undeniable need to pay close attention to their psychological well-being. Measures need to be undertaken to ensure their physical and mental health and wellness.

A retrospective analysis of peri-operative medication errors from a low-middle income country

Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004–2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.

Publication dynamics: what can be done to eliminate barriers to publishing full manuscripts by the postgraduate trainees of a low-middle income country?

Objectives
This study aimed to determine the publication rate of free paper abstracts presented by the postgraduate (PG) trainees and determine the reasons for non-publication. A mixed methods study was conducted. PG trainees presenting free papers at the at the Pakistan Society of Chemical Pathologist conferences from 2012 to 2018 were included. Three databases were searched to identify if the abstracts were published or not. The PG trainee authors of abstracts not published as full manuscript, were surveyed to determine the barriers and challenges in publishing a manuscript.

Results
The average rate of full manuscript publication was 51.8% (n = 93/177) for the abstracts presented by the PG trainees. Publication rate was higher for oral (n = 73/119, 61.3%) compared to poster presentation (n = 20/58, 34.5%). Most of the manuscripts were published after two years of abstract presentation. The survey showed that the main challenges to publishing an abstract were lack of time, limited scientific writing or submission skills, lack of funding for publication fee, and negative or statistically non-significant results. This reflects a need to arrange workshops/symposia for the PG trainees of low-middle income country (LMIC) to enhance their writing and time management skills and improve the full manuscript publication rate from LMICs.

Association of social & psychological aspects of quality of life and educational level of patients with different orofacial cleft

Objective: To determine the social and psychological domains of quality of life of children with orofacial clefts in the context of different types of clefts and educational levels.

Method: The cross-sectional study was conducted at Clapp Hospital and Mayo Hospital, Lahore, Pakistan from September 1, 2020, to January 3, 2021, and comprised subjects of either gender aged 6-18 years having orofacial clefts. Data was collected using the CLEFT-Questionnaire along with a basic demographic sheet. Data was analysed using SPSS 23.

Results: Of the 80 subjects, 40(50%) each were males and females. The overall mean age was 12.41±3.39 years. A significant association of types of orofacial clefts with social function (p<0.05) and psychological function (p0.05) and psychological function (p>0.05) was noted.

Conclusion: Different types of orofacial clefts affected the psychological and social aspects of quality of life of patients differently, but the difference was not significantly correlated with the education level.

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.