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 <0.05 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, 74.7% 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.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations

Objective
A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.

Design
A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.

Results
Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.

Conclusions
A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Impact of COVID-19 on Cardiovascular Disease Presentation, Emergency Department Triage and Inpatient Cardiology Services in a Low- to Middle-Income Country – Perspective from a Tertiary Care Hospital of Pakistan

Aims: To identify the changes in cardiovascular disease presentation, emergency room triage and inpatient diagnostic and therapeutic pathways.

Methods: We conducted a retrospective cohort study at the Aga Khan University Hospital, Karachi. We collected data for patients presenting to the emergency department with cardiovascular symptoms between March–July 2019 (pre-COVID period) and March–July 2020 (COVID period). The comparison was made to quantify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, and in-hospital mortality between the two periods.

Results: Of 2976 patients presenting with cardiac complaints to the emergency department (ED), 2041(69%) patients presented during the pre-COVID period, and 935 (31%) patients presented during the COVID period. There was significant reduction in acute coronary syndrome (ACS) (8% [95% CI 4–11], p < 0.001) and heart failure (↓6% [95% CI 3–8], p < 0.001). A striking surge was noted in Type II Myocardial injury (↑18% [95% CI 20–15], p < 0.001) during the pandemic. There was reduction in cardiovascular admissions (coronary care unit p < 0.01, coronary step-down unit p = 0.03), cardiovascular imaging (p < 0.001), and procedures (percutaneous coronary intervention p = 0.04 and coronary angiography p = 0.02). No significant difference was noted in mortality (4.7% vs. 3.7%). The percentage of patients presenting from rural areas declined significantly during the COVID period (18% vs. 14%, p = 0.01). In the subgroup analysis of sex, we noticed a falling trend of intervention performed in females during the COVID period (8.2% male vs. 3.3 % female). Conclusions: This study shows a significant decline in patients presenting with Type I myocardial infarction (MI) and a decrease in cardiovascular imaging and procedures during the COVID period. There was a significant increase noted in Type II MI.

Lessons learnt from emergency medicine services during the COVID-19 pandemic: A case study of India and the United States

India and the United States have both witnessed a high burden of COVID-19 infections since the pandemic was declared in early 2020. However, the COVID-19 restrictions have met with mixed responses in India and the US. Despite recommendations to continue social isolation and personal hygiene measures, India has not been able to curb the rise in daily cases. Our findings demonstrate the difference in the manner by which India and the US differ in their emergency handling of patients. We conducted a thorough review of the existing protocols and data concerning emergency responses in India and the US. The triage and care of suspected COVID-19 positive patients is different across India and the US. We find that there is a shortage of oxygenation, vaccination and other essential supplies in India. Further, the US is able to triage patients through telemedicine and EMS before suspected COVID-19 patients arrive, which is less prevalent in India. Our study identifies the importance of the emergency department (ED) as a critical contributor to the prevention and care of suspected and confirmed COVID-19 patients. Hospitals in India have been struggling to accommodate a huge influx of patients during its second wave with the ED playing a key link in their COVID-19 response.

Looking ahead in the COVID-19 pandemic: emerging lessons learned for sexual and reproductive health services in low- and middle-income countries

The COVID-19 pandemic has caused widespread disruption to essential health service provision globally, including in low- and middle-income countries (LMICs). Recognising the criticality of sexual and reproductive health (SRH) services, we review the actual reported impact of the COVID-19 pandemic on SRH service provision and evidence of adaptations that have been implemented to date. Across LMICs, the available data suggests that there was a reduction in access to SRH services, including family planning (FP) counselling and contraception access, and safe abortion during the early phase of the pandemic, especially when movement restrictions were in place. However, services were quickly restored, or alternatives to service provision (adaptations) were explored in many LMICs. Cases of gender-based violence (GBV) increased, with one in two women reporting that they have or know a woman who has experienced violence since the beginning of the pandemic. As per available evidence, many adaptations that have been implemented to date have been digitised, focused on getting SRH services closer to women. Through the pandemic, several LMIC governments have provided guidelines to support SRH service delivery. In addition, non-governmental organisations working in SRH programming have played significant roles in ensuring SRH services have been sustained by implementing several interventions at different levels of scale and to varying success. Most adaptations have focused on FP, with limited attention placed on GBV. Many adaptations have been implemented based on guidance and best practices and, in many cases, leveraged evidence-based interventions. However, some adaptations appear to have simply been the sensible thing to do. Where evaluations have been carried out, many have highlighted increased outputs and efficiency following the implementation of various adaptations. However, there is limited published evidence on their effectiveness, cost, value for money, acceptability, feasibility, and sustainability. In addition, the pandemic has been viewed as a homogenous event without recognising its troughs and waves or disentangling effects of response measures such as lockdowns from the pandemic itself. As the pandemic continues, neglected SRH services like those targeting GBV need to be urgently scaled up, and those being implemented with any adaptations should be rigorously tested.

Oncology nursing in the Global South during COVID-19

In mid-2020, a call was made to oncology nurses in the Global South to share their experiences managing patient care during the coronavirus disease 2019 (COVID-19) pandemic. Eighteen submissions were received from 16 countries across Latin America, Africa, Europe and Asia. Three were research-based and 15 were personal narratives on the psychosocial impact of COVID-19 on the nurses, colleagues, patients and families. Three narratives were from oncology nurses working with cancer-related non-governmental organisations locally or, in one case, internationally. A simultaneous literature search for publications (including grey literature) was performed to identify themes of COVID-19’s impact in these 16 countries and specifically on oncology nurses and patients/families. Four themes were identified: a) interruptions to care; b) support/resource shortages; c) psychosocial impact on nurses and patients and d) staffing and nursing role impacts. The three research-based studies describe oncology nursing in-depth efforts to explore the impact of COVID-19. Findings in the 15 narratives are briefly presented according to the four themes identified in the literature. Due to the severe shortage of physician adult and paediatric oncology specialists, oncology nurses in the Global South often shoulder much of the care for patients with cancer and even more so during COVID-19 with attendant oncology nursing shortages due to reassignment to COVID-19 units. It is important to hear from these critical members of the oncology nursing workforce who often lack the time, resources or training to publish in peer-reviewed journals in English, particularly in the middle of a pandemic. Giving voice to these nurses documents the reality of their work and ability to continue to provide care despite the chaos and rapidly changing guidelines and government action. Lessons learned by these nurses to improve mental health and psychosocial support of the nurses as well as their patients/families will be essential for the next global pandemic.

Exploring the lived experiences of pregnant women and community health care providers during the pandemic of COVID-19 in Bangladesh through a phenomenological analysis

Background
Like many countries, the government of Bangladesh also imposed stay-at-home orders to restrict the spread of severe acute respiratory syndrome coronavirus-2 (COVID-19) in March, 2020. Epidemiological studies were undertaken to estimate the early possible unforeseen effects on maternal mortality due to the disruption of services during the lockdown. Little is known about the constraints faced by the pregnant women and community health workers in accessing and providing basic obstetric services during the pandemic in the country. This study was conducted to explore the lived experience of pregnant women and community health care providers from two southern districts of Bangladesh during the pandemic of COVID-19.

Methods
The study participants were recruited through purposive sampling and non-structured in-depth interviews were conducted. Data was collected over the telephone from April to June, 2020. The data collected was analyzed through a phenomenological approach.

Results
Our analysis shows that community health care providers are working under tremendous strains of work load, fear of getting infected and physical and mental fatigue in a widely disrupted health system. Despite the fear of getting infected, the health workers are reluctant to wear personal protective suits because of gender norms. Similarly, the lived experience of pregnant women shows that they are feeling helpless; the joyful event of pregnancy has suddenly turned into a constant fear and stress. They are living in a limbo of hope and despair with a belief that only God could save their lives.

Conclusion
The results of the study present the vulnerability of pregnant women and health workers during the pandemic. It recognizes the challenges and constraints, emphasizing the crucial need for government and non-government organizations to improve maternal and newborn health services to protect the pregnant women and health workers as they face predicted waves of the pandemic in the futur

Impact of COVID-19 pandemic on global burn care

Background
Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care.

Methods
The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher’s exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic.

Results
The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p=0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p=0.04). Use of telemedicine was implemented (p<0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors.

Conclusions
During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.

Restrictive abortion laws, COVID-19, telehealth, and medication abortion in the SDG era

Annual worldwide abortion rates reportedly increased from 55·7 million between 2010 and 2014, to 73·3 million in 2015–19.1, 2 About 4·7–13·2% of maternal deaths annually are abortion-related, with the highest burden in Asia and Africa.3 Elimination of unsafe abortion, defined by WHO4 as “an abortion that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both”, is therefore a critical step towards achieving the UN Sustainable Development Goal (SDG) target of reducing the global maternal mortality ratio to less than 70 per 100 000 livebirths (SDG 3.1) and ensuring universal access to sexual and reproductive health-care services by 2030 (SDG 3.7). Some of the relevant factors that might impact positively on abortion-related morbidity and mortality are discussed here.
Asia, Latin America, and Africa have some of the most legally restrictive abortion laws, yet these regions account for 97% of the global burden of unsafe abortions.1, 3 Abortion rates in settings with restrictive laws are not necessarily lower than in regions with permissive laws. In fact, almost 62% of all abortion-related deaths are recorded in Africa alone.3 These predominantly restrictive abortion laws lead to delayed decisions to seek care until advanced gestational ages, when the abortion becomes more difficult to undertake, and care is often sought from clandestine sources to circumvent the law. Nigeria and Argentina, which were selected by Heidi Moseson and colleagues5 for their research, are countries with some of the highest rates of unsafe abortion. Therefore, the findings of this research are relevant to many other countries with similar prevailing circumstances.
The American College of Obstetrics and Gynaecology defines telehealth as “the technology-enhanced health care framework that includes services such as virtual visits, remote patient monitoring, and mobile health care”.6 With the COVID-19 pandemic, use of telehealth has become widespread in many aspects of health-care delivery systems. Specifically, with respect to abortion, telehealth not only facilitates access for women seeking abortion services, but also provides the additional benefits of confidentiality and avoidance of stigmatisation, with similar clinical outcomes to facility-based management.7, 8 However, in low-income and middle-income countries (LMICs), such as Nigeria, termination for any reason apart from saving maternal life is not only illegal, but the provider of such medications and services is liable to 14 years imprisonment. Such laws might significantly impede the optimal use of telehealth for abortion services across various regions of the world.
Medication abortion has been in use for at least two decades, with current regimens including misoprostol alone and misoprostol and mifepristone in combination. Evidence supports the effectiveness and efficiency of medication abortion, especially in pregnancies of less than 10 weeks, which was further affirmed by the findings from Moseson and colleagues.5 Medication abortion is also associated with lower risks of cervical injuries, uterine perforations, and post-abortion sepsis than is surgical abortion, and might therefore reduce abortion-related morbidity and maternal mortality.9, 10 However, conventional medication abortion is physician supervised, and initially involves hospital admission. The cost of health facility visits can be prohibitive in LMICs, where people pay out-of-pocket for health care and might be living on less than US$1 per day.
Apart from the social stigma associated with abortion, women cannot seek health care without the permission and accompaniment of a male relative in some cultural and religious settings. Moseson and colleagues5 showed that self-managed medication abortion is highly effective at early gestational ages, obviating the need for health facility visits. The study also showed that home-managed abortion with accompaniment support by trained, non-medical personnel was non-inferior to historical controls who underwent physician-supervised, facility-based management. These findings might influence access to and safe management of abortion, thereby facilitating reproductive health decision making by women, with more efficient use of resources through telemedicine and task shifting. However, such benefits might remain impossible to explore in settings with restrictive abortion laws.
There is also a need to balance these benefits against the possibility of abuse, exploitation, and forced abortions by male partners at home, especially in settings where women are less empowered to make decisions concerning their reproductive health. Further qualitative research is needed for strategic planning towards SDG targets 3.1 and 3.7. Although this can be achieved without hindrance in some settings, it is unclear how much data might be obtainable from regions within restrictive abortion jurisdictions, where the line between legality and illegality could easily be crossed by researchers unless laws are revised.
We declare no competing interests.

The accountability of the private sector towards citizens in times of crisis: vaccines, medicines and equipment

In this article, we examine what the role of the private sector in times of crises is and whether the private sector is, and can be held to be, accountable. COVID-19 has amplified the difficulties with public–private partnerships and this article addresses several aspects concerning business enterprises, in particular transnational corporations, human rights and health sector activities, highlighting the key aspects to understand and address accountability issues. The article also explores accountability for the private sector, the processes to ensure accountability, and the relevance of regulation and self-regulation.