Clinical Profile and Predictors of Mortality in Neonates Born With Non-Immune Hydrops Fetalis: Experience From a Lower-Middle-Income Country

Introduction
Hydrops fetalis (HF) is a life-threatening condition in which a fetus has an abnormal collection of fluid in the tissue around the lungs, heart, abdomen, or under the skin. Based on its pathophysiology, it is classified into immune and non-immune types. With the widespread use of anti-D immunoglobulin, non-immune HF has become more common, with an incidence of one in 1,700-3,000 live births. A multitude of fetal diseases with various causes can lead to non-immune HF. Due to the recent advances in prenatal diagnostic and therapeutic interventions together with improved neonatal intensive care, the diagnosis and subsequent management of HF have been refined. However, HF is still associated with a high mortality rate. A recent assessment of the literature found that there is a lack of data on prognostic variables in neonates with HF from low- and middle-income countries. In light of this, we sought to establish the etiologic causes, predictors of mortality, and eventual fate of newborns born non-immune HF at the Aga Khan University Hospital, Karachi during the 10-year period spanning January 2009-December 2019 in this retrospective analysis.

Methodology
For this study, we collected data from the computerized database and patient record files at the hospital on all infants with non-immune HF. Demographic data, postnatal interventions, clinical and laboratory findings, outcomes, and the results of comparison between HF patients who died and those who survived were analyzed.

Results
The incidence of non-immune HF at our hospital was 0.62/1,000 live births during the period under study, with 33 newborn babies diagnosed with non-immune HF from a total of 53,033 live-born deliveries. An etiologic factor was discovered in 17 (51.5%) neonates with non-immune HF while 16 (48.4%) were classified as those with unidentified etiology. The most common causes were cardiovascular and genetic syndromes, which resulted in 100% mortality. The overall mortality rate was 67%. The need for mechanical ventilation, surfactant therapy, and prolonged hospitalization were identified as independent risk factors of mortality.

Conclusion
Our study proves that the need for mechanical ventilation [moderate to severe hypoxic respiratory failure (HRF)] and prolonged hospitalization are strong predictors of poor outcomes in neonates with non-immune HF. Therefore, severe hydrops causing significant mortality can be anticipated based on the patients’ respiratory status and the need for escalated oxygen support.

The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan

Dear Editor

Defined as “the use of information and telecommunication technologies (ICT) in medicine, telemedicine intends to provide appropriate healthcare at a distance, hence eliminating the need for direct contact between a patient and physician [1]. It can be classified according to the type of interaction (pre-recorded or real-time) and type of format in which information is conveyed (videos, pictures, audio, etc.) [2]. Particularly in the setting of a natural or man-made disaster, telemedicine is known to function as a key component in the emergency response, enabling people to access routine care and health support despite widespread disruptions in health services [3].

The relevance of telemedicine to our health systems is more evident than ever today as we continue to battle the COVID- 19 pandemic that has modified our lifestyle and approach to medical care. In the face of lockdowns and social distancing protocols, telemedicine technologies are being employed for online consultations, monitoring and evaluating symptoms, tracking and circumventing COVID-19 hotspots, and addressing individual concerns through chat bots [4].

Although the age of COVID-19 has significantly propelled the adoption of telemedicine services globally, its market was booming even prior to the onset of the COVID-19 pandemic, with a market size estimated around US$50 billion as of 2019, projected to increase over 9-fold in the coming decade [5]. A growing body of literature supports the role of telemedicine in providing timely, affordable, and premium quality healthcare services surpassing geographical barriers, which is especially advantageous for resource limited countries. However, while it is being integrated in the health infrastructure in USA, Europe and South East Asia with increasing momentum, its future in the developing world remains obscure [6].

Although the rate is considerably slower than developed countries, developing countries are gradually adapting to the changing times with efforts to make high-quality healthcare accessible to the masses from the comfort of their residence via digital interventions. Sub-Saharan Africa, for example, has reported a significant increase in mobile health technology [7]. The implementation of telemedicine amid a concomitant burden of communicable and non-communicable diseases in low and middle income countries (LMICs) can have consequential impacts in addressing the basic health needs of the population. By reducing travel costs and time, telemedicine enables rural and marginalized communities to access the same quality of medical resources and care as urban dwellers, and promotes health equity [6].

Reimagining Universal Health Coverage: Safe and Affordable Surgery

UN sustainable development goals (SDGs) and universal health coverage (UHC) are significant health goals the world needs to achieve. Despite concerted efforts to attain UHC, the world is still lagging. Compared to the sizable number of resources put into the treatment of well-known communicable diseases, such as HIV/AIDs, tuberculosis, and malaria, surgery is relatively underutilized despite its potential. Scaling up surgical interventions, however, is crucial since it can save many people’s lives and help avert the economic losses incurred due to diseases. Moreover, increased surgical capacity in low-to-middle-income countries (LMICs) could prove useful in overcoming pandemics, such as COVID-19. To upgrade the surgical capacity of the LMICs, it is essential to incorporate National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) into their national health policies. In this paper, the illustrative cases of two countries that adopted NSOAPs with a different model. Zambia and Pakistan, are examined. We conclude by giving recommendations to countries that are yet to adopt NSOAPs

Quality of Life in Patients Undergoing Cardiac Surgery: Role of Coping Strategies

Adaptive coping strategies are used to reduce stress in patients undergoing cardiac surgery. These strategies have a major role in physical health, psychological health, quality of life and also affect an individual’s response to the disease. The current study was conducted to comprehend the impact of coping strategies on the quality of life of patients suffering from cardiac disease. A purposive convenient sampling method was used to collect data from different hospitals in South Punjab. We applied Carver’s Brief Coping Orientation to Problem Experienced (Brief COPE) inventory and the WHO quality of life scale. A cross-sectional research design was proposed for the study. The findings of the study showed that coping strategies and quality of life are associated with each other, and the use of emotion-focused and problem-focused coping strategies have a significant impact on patients experiencing cardiac surgery. Demographic details of patients also revealed the differences in both variables. Implications and future recommendations have also been discussed.

Emergency Department Outcome of Patients with Traumatic Brain Injury – A Retrospective Study from Pakistan

Introduction: Traumatic brain injury (TBI) is a leading cause of global morbidity and mortality in both adults and children. As with other severe injuries, the outcome of TBIs is also gravely related to the quality of emergency care. Effective emergency care significantly contributes to reduced morbidity and mortality. This study was ensued to evaluate the characteristics of TBIs in Pakistan and their outcomes in the emergency department (ED).

Methods: This retrospective review included records of all TBI patients seen in the Neurosurgical ED of Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st September 2019 till 7th December 2019.

Results: During the study period, 5,546 patients with TBI were seen in the ED; an estimated 56.5 patients per day. There were 4,054 (73.1%) male and 1,492 (26.9%) female patients. Most of these (26%) were of age <10 years. The most common culprit of TBI was road traffic accidents (RTAs) (n=2,163; 39%) followed by accidental fall (n=1,785; 32.2%). Head injury was mostly mild (n=4,034; 72.8%) and only 265 (4.7%) had a severe injury. Only 10% (n=549) patients were admitted for further treatment, 16% were managed in the ED then discharged, and 67% were immediately discharged from the ED after the first examination and necessary management. The ED mortality rate of TBIs was 2.2% (n=123/5,546) in our study. All of these cases had severe head injuries.

Conclusion: Major culprits of TBI are RTAs and accidental falls. TBIs are mostly mild-to-moderate and the ED mortality rate is low.

Comparison of Challenges and Problems Encountered in the Practice of Exclusive Breast Feeding by Primiparous and Multiparous Women in Rural Areas of Sindh, Pakistan: A Cross-Sectional Study

Introduction: The UNICEF (United Nations International Children Education Fund) and WHO (World Health Organization) recommend exclusive breastfeeding (EBF) for the first six months of life. EBF is considered to be an important practice for enhancing infant health and wellbeing. Breastfeeding offers a wide range of psychological and physical health benefits in the long-term and short-term for young children, infants, and mothers. This study aims to compare exclusive breastfeeding practice among primiparous and multiparous mothers including reasons for discontinuing exclusive breastfeeding and problems faced during breastfeeding.

Methodology: This cross-sectional study was conducted in rural areas of Sindh, registered with the Maternal Newborn Health Registry (MNHR). The study used a systematic sampling technique for the enrollment of study participants. A survey questionnaire was used to collect data from mothers about the practices of EBF. A total of 397 mothers were interviewed and analyzed.

Results: Among Primiparous mothers, 14.1% of mothers initiated breastfeeding within one hour of birth, while 22.4% of multiparous mothers, initiated breastfeeding within one hour of birth. The difference between the two is statistically insignificant (p-value=0.234). A high percentage of multiparous mothers exclusively breastfed their infants for six months (63.5%) as compared to primiparous mothers (51.5%). The most common reason for introducing pre-lacteal feed before six months among primiparous mothers is the lack of adequate milk production to fulfill baby needs; this was the case for 35.4% of mothers. On the other hand, the baby remaining hungry post breastfeeding was the major reason among multiparous mothers (44.0%) for introducing pre-lacteal feed before six months.

Conclusion: This study helped in the identification of issues faced by primiparous and multiparous mothers during exclusive breastfeeding. Interventions for promoting EBF need to be tailored as per the need and challenges of the population.

Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017–2018)

Background
Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.

Methods
We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017–2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights.

Results
Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women’s age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42–1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18–1.33]), primary education (aPR = 1.33; [95% CI: 1.24–1.43), secondary education (aPR = 1.34; [95% CI: 1.26–1.43), higher education (aPR = 2.13; [95% CI: 1.97–2.30), women’s say in choosing husband (aPR = 1.68; [95% CI: 1.57–1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43–2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23–1.36]) were significantly associated with iron consumption for ≥90 days.

Conclusion
These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.

eHealth for service delivery in conflict: a narrative review of the application of eHealth technologies in contemporary conflict settings

The role of eHealth in conflict settings is increasingly important to address geographic, epidemiologic and clinical disparities. This study categorizes various forms of eHealth usage in conflict and aims to identify gaps in evidence to make recommendations for further research and practice. The analysis was carried out via a narrative hermeneutic review methodology. Articles that fulfilled the following screening criteria were reviewed: (1) describing an eHealth intervention in active conflict or ongoing insurgency, (2) an eHealth intervention targeting a conflict-affected population, (3) an e-learning platform for delivery in conflict settings and (4) non-interventional descriptive reviews relating to eHealth in conflict. Of the 489 papers eligible for screening, 46 merited final inclusion. Conflict settings described include Somalia, Sudan, Afghanistan, Syria, Iraq, Pakistan, Chechnya, Gaza and the Democratic Republic of Congo. Thirty-six studies described specific eHealth initiatives, while the remainder were more generic review papers exploring general principles. Analysis resulted in the elucidation of three final categories of current eHealth activity in conflict-affected settings: (1) eHealth for clinical management, (2) e-learning for healthcare in conflict and (3) eHealth for information management in conflict. Obvious disparities in the distribution of technological dividends from eHealth in conflict are demonstrated by this review. Conflict-affected populations are predominantly subject to ad hoc and voluntary initiatives delivered by diaspora and civil society organizations. While the deployment of eHealth technologies in conflict settings is increasingly normalized, there is a need for further clarification of global norms relating to practice in this context.

Fears and barriers: problems in breast cancer diagnosis and treatment in Pakistan

Background
Women in Pakistan lack appropriate awareness about diagnosis and treatment for breast cancer due to a range of multifaceted barriers. There is a dearth of literature examining the socio-cultural factors that inhibit women from breast cancer screening, diagnosis and treatment in Punjab, Pakistan. Addressing this gap, this qualitative study sought to identify and explore the barriers that hinder women from seeking timely screening and treatment.

Methods
In this process 45 women (age = 18–50 years) with breast cancer were purposively sampled and interviewed from the Punjab Institute of Nuclear Medicine (PINUM) hospital, Faisalabad, Pakistan.

Results
An inductive approach was used to analyze the data which resulted in the emergence of eight subthemes under the umbrella of three major themes that delineate individual, socio-cultural and structural barriers to seek screening and treatment of breast cancer in Punjab. Individual barriers included lack of awareness, hesitance in accepting social support, and spiritual healing. The identified socio-cultural factors included feminine sensitivity, stigmatization, and aversion to male doctors. Lack of financial resources and apathetic medical services were structural barriers that hinder screening and treatment.

Conclusions
These barriers can be addressed through raising awareness and community mobilization about breast-self exam and treatment. The healthcare system should also pay attention to socio-psychological and cultural factors impeding women’s access to available health facilities.

Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

Background and objectives
The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods
This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results
In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion
Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and saf