Abstract Objective Motorcyclists are frequently involved in road traffic accidents and may suffer... more Abstract Objective Motorcyclists are frequently involved in road traffic accidents and may suffer polytraumatic injuries, contributing a substantial burden on healthcare systems particularly in lower-middle-income countries. This study aimed to describe patterns of injury, in-hospital course, and outcomes of road accident trauma in motorcyclists, including polytrauma, at a Trauma Facility in Pakistan. Methods A retrospective review was conducted by using relevant trauma codes to extract data from records for all victims presenting with motorcycle trauma between January 2018 and June 2019, to a tertiary care hospital in Pakistan. Data collected included victim characteristics, mechanism of accident, patterns of traumatic injury, management, in-hospital complications, and outcomes. Polytrauma was defined as traumatic injuries in two or more anatomic regions with abbreviated injury scale (AIS) ≥ 3. Multivariable logistic regression, adjusted for age, gender, and mechanism of accident, was performed to identify in-hospital complications and outcomes associated with polytrauma. Results A total of 514 victims, 90.9% male and 39.5% aged between 18-30 years, were included in this study. The victim was the motorcycle driver in 94.6% of cases. The most common mechanism of accident was motorcycle vs. other motor vehicle (56.2%). Patients were mostly admitted under the services of Orthopedic Surgery (50.8%) and Neurosurgery (30%), with common sites of injury being the lower extremity (42.6%), head (38.1%), and upper extremity (26.8%). Polytrauma occurred in 19.5% of victims. Patients were managed surgically in 77.3% of cases, with the most common procedure being open reduction of fractures (48.1%). Blood transfusion was required in 4.1% of patients. The commonest in-hospital complication was acute kidney injury (23.7%). The median length of stay was 3 days, and 4.1% of patients expired in the hospital. Polytrauma was significantly associated with the need for blood transfusion (2.642 [1.053–6.630]), AKI (2.212 [1.339–3.652]) and hospital length of stay (1.059 [1.025–1.094]), but not with mortality. Conclusion Although orthopedic injuries occur most frequently in motorcycle trauma, polytrauma necessitating multi-disciplinary management and complicating hospital stay is also common. Understanding patterns of injuries and management in motorcycle trauma will enable trauma teams in a developing country like Pakistan to devise evidence-based management protocols, especially for cases of polytrauma.
Global Journal on Quality and Safety in Healthcare, 2020
Introduction Value in health care has been defined as health outcomes achieved per dollar spent. ... more Introduction Value in health care has been defined as health outcomes achieved per dollar spent. The concept of value is a shift from the traditional volume-based health delivery system. The implementation of value-based health care has generally been at an institutional level. The objective of our study was to calculate and compare the value of health care delivered by nine individual surgeons at a single institution for laparoscopic cholecystectomies, at the level of the provider. Methods Data were collected for laparoscopic cholecystectomies performed over 2 years from January 1, 2016, to December 31, 2017. Only elective cholecystectomies performed for noninflamed gall bladder were included in the analysis. Any patients admitted through the emergency department were excluded. Patients who had comorbidities requiring further workup after admission were also excluded. To the best of our knowledge, there is no published model for determining value at the level of the provider. Hence...
JPMA. The Journal of the Pakistan Medical Association, 2020
Early rectal cancer management includes tumour stages TiS, T1 and some selected T2 lesions that u... more Early rectal cancer management includes tumour stages TiS, T1 and some selected T2 lesions that undergo appropriate clinical pre-operatie evaluation. Local excision of these lesions with acceptable recurrence rate can be achieved through various transanal endoscopic techniques like transanal endoscopic microsurgery (TEM) and transanal minimal invasive surgery (TAMIS) that are superior to simple transanal excision (TAE). The current literature review was planned to present the oncological evaluation of local excision in the context of available evidence. An overview of perioperative adjuvant therapies employed along with local excision is presented, with an update on the latest trials.
JPMA. The Journal of the Pakistan Medical Association, 2019
Trauma registry plays an essential role in collecting epidemiological injury data which is used i... more Trauma registry plays an essential role in collecting epidemiological injury data which is used in quality care improvement and research. This paper was planned toshare our experience of having developed a low-budget user-friendly trauma registry with the help of Microsoft Access. This was used because of its ease of use, quickdevelopment style, and support for relational database d esign. Var iable i nc lud ed in our registr y were demographics, description of injury, International Classification of Disease 9 Clinical Modification (ICD9- CM) external injury classification codes, date and time of arrival, length of hospital stay, referral to and from hospital, physiological assessment along with scores for assessing the injury severity. Developing a local trauma registry helped us in scrutinising our practice, and we believe that a national or regional trauma registry is the need of the hour in Pakistan. This will highlight the concerns specific to our society in providing quality t...
The developing world shares the paramount proportions of global surgical complications. The surgi... more The developing world shares the paramount proportions of global surgical complications. The surging population grappling with lack of resources and awareness and poor quality healthcare infrastructure are a few of the many factors faced by the population of 2.9 billion people. The charting of data regarding post-surgical complications is deficient and no national average is present for comparison. In this context, the implementation of the US-based ACS-National Surgical Quality Improvement Program (NSQIP) that compares hospital performance on basis of post-surgical complication data provided by the wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To the best of our knowledge, this report is the first from a low-middle income country to report its postoperative neurosurgical complications in comparison with international benchmarks. We hope that with a relatively higher reported rate of surgical complications and mortalities in the developing world, the implementation of the NSQIP program can act as an important catalyst in taking important measures. For a specialty like neurosurgery in particular where the consequences of surgical complications are much higher, NSQIP can perhaps have an even greater impact. In this article, we will provide our hospital's initial experience with NSQIP and will also share the learning points derived from it.
Gastric volvulus is a rare surgical emergency which mostly presents in children and occasionally ... more Gastric volvulus is a rare surgical emergency which mostly presents in children and occasionally in adults. It results due to pathological malrotaion of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and caries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed. Keywords: Gastric Volvulus, Malrotation, Vomiting, Continuous...
Objective: Trauma is the significant non-obstetrical cause of maternal mortality in women aged 35... more Objective: Trauma is the significant non-obstetrical cause of maternal mortality in women aged 35 years or younger. It is expected to complicate around 1 in 12 pregnancies and accounts for 46% of such deaths. In this study, we present our experience of trauma during pregnancy at a tertiary care hospital in Karachi. Methods: A standardized form was used to extract data from online records for all pregnant women who presented with traumatic injuries to the Aga Khan University Hospital from 2014 to 2019. Analysis was performed using SPSS v. 21. Chi-squared tests were performed for comparison of categorical data. Results: A total of 48 pregnant females with a mean age of 28.80 ± 6.50 years were included in this study. Road traffic accidents (RTA) accounted for the commonest cause of injury in the first (66.7%) and second (65%) trimesters. However, fall (45.5%) followed by RTA (27.3%) was the most frequent mechanism of injury during the third trimester. Gunshot injuries were seen in 4 pa...
Introduction Trauma is the leading cause of death among a younger population not only in USA but ... more Introduction Trauma is the leading cause of death among a younger population not only in USA but in Pakistan as well. The high prevalence of disease should result in a larger amount of data and a larger number of publications resulting in the ability to explore improvements in the field. This study aimed to review the trauma literature generated from Pakistan. Methods Journals indexed with PubMed from January 2010 to December 2014 were searched using the search term “Trauma AND Pakistan” filtering for relevant dates and human reports only. The abstracts and articles were reviewed by the authors to collect data on a proforma. Results 114 articles were published from Pakistan during these five years; 64% of articles were published in international journals; 63% of articles were published in journals with an Impact Factor less than 1; 54% of articles were published from one of four provinces of Pakistan; 64% of articles provided Level 4 evidence whilst another 14% of articles provided ...
Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very ... more Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very high mortality. Time is of essence and if not promptly recognised these injuries could have devastating consequences. We report a case emphasising the importance of oesophagoscopy in diagnosing oesophageal injuries. A young man presented to our emergency ward as an unwitnessed road traffic accident after receiving first aid from a secondary care facility. At presentation, he was haemodynamically stable with decreased power in lower limbs, and with severe neck and back pain. There was high suspicion of spinal injury, which was later evident on clinical and on radiological findings. A CT scan revealed oesophageal injury, indicated by contrast extravasation, which was convincing enough to proceed without endoscopy. Surprisingly, the apparently convincing injury picked up on CT scan marked by contrast extravasation turned out to be an artefact, which led to a negative surgical exploration.
Abstract Objective Motorcyclists are frequently involved in road traffic accidents and may suffer... more Abstract Objective Motorcyclists are frequently involved in road traffic accidents and may suffer polytraumatic injuries, contributing a substantial burden on healthcare systems particularly in lower-middle-income countries. This study aimed to describe patterns of injury, in-hospital course, and outcomes of road accident trauma in motorcyclists, including polytrauma, at a Trauma Facility in Pakistan. Methods A retrospective review was conducted by using relevant trauma codes to extract data from records for all victims presenting with motorcycle trauma between January 2018 and June 2019, to a tertiary care hospital in Pakistan. Data collected included victim characteristics, mechanism of accident, patterns of traumatic injury, management, in-hospital complications, and outcomes. Polytrauma was defined as traumatic injuries in two or more anatomic regions with abbreviated injury scale (AIS) ≥ 3. Multivariable logistic regression, adjusted for age, gender, and mechanism of accident, was performed to identify in-hospital complications and outcomes associated with polytrauma. Results A total of 514 victims, 90.9% male and 39.5% aged between 18-30 years, were included in this study. The victim was the motorcycle driver in 94.6% of cases. The most common mechanism of accident was motorcycle vs. other motor vehicle (56.2%). Patients were mostly admitted under the services of Orthopedic Surgery (50.8%) and Neurosurgery (30%), with common sites of injury being the lower extremity (42.6%), head (38.1%), and upper extremity (26.8%). Polytrauma occurred in 19.5% of victims. Patients were managed surgically in 77.3% of cases, with the most common procedure being open reduction of fractures (48.1%). Blood transfusion was required in 4.1% of patients. The commonest in-hospital complication was acute kidney injury (23.7%). The median length of stay was 3 days, and 4.1% of patients expired in the hospital. Polytrauma was significantly associated with the need for blood transfusion (2.642 [1.053–6.630]), AKI (2.212 [1.339–3.652]) and hospital length of stay (1.059 [1.025–1.094]), but not with mortality. Conclusion Although orthopedic injuries occur most frequently in motorcycle trauma, polytrauma necessitating multi-disciplinary management and complicating hospital stay is also common. Understanding patterns of injuries and management in motorcycle trauma will enable trauma teams in a developing country like Pakistan to devise evidence-based management protocols, especially for cases of polytrauma.
Global Journal on Quality and Safety in Healthcare, 2020
Introduction Value in health care has been defined as health outcomes achieved per dollar spent. ... more Introduction Value in health care has been defined as health outcomes achieved per dollar spent. The concept of value is a shift from the traditional volume-based health delivery system. The implementation of value-based health care has generally been at an institutional level. The objective of our study was to calculate and compare the value of health care delivered by nine individual surgeons at a single institution for laparoscopic cholecystectomies, at the level of the provider. Methods Data were collected for laparoscopic cholecystectomies performed over 2 years from January 1, 2016, to December 31, 2017. Only elective cholecystectomies performed for noninflamed gall bladder were included in the analysis. Any patients admitted through the emergency department were excluded. Patients who had comorbidities requiring further workup after admission were also excluded. To the best of our knowledge, there is no published model for determining value at the level of the provider. Hence...
JPMA. The Journal of the Pakistan Medical Association, 2020
Early rectal cancer management includes tumour stages TiS, T1 and some selected T2 lesions that u... more Early rectal cancer management includes tumour stages TiS, T1 and some selected T2 lesions that undergo appropriate clinical pre-operatie evaluation. Local excision of these lesions with acceptable recurrence rate can be achieved through various transanal endoscopic techniques like transanal endoscopic microsurgery (TEM) and transanal minimal invasive surgery (TAMIS) that are superior to simple transanal excision (TAE). The current literature review was planned to present the oncological evaluation of local excision in the context of available evidence. An overview of perioperative adjuvant therapies employed along with local excision is presented, with an update on the latest trials.
JPMA. The Journal of the Pakistan Medical Association, 2019
Trauma registry plays an essential role in collecting epidemiological injury data which is used i... more Trauma registry plays an essential role in collecting epidemiological injury data which is used in quality care improvement and research. This paper was planned toshare our experience of having developed a low-budget user-friendly trauma registry with the help of Microsoft Access. This was used because of its ease of use, quickdevelopment style, and support for relational database d esign. Var iable i nc lud ed in our registr y were demographics, description of injury, International Classification of Disease 9 Clinical Modification (ICD9- CM) external injury classification codes, date and time of arrival, length of hospital stay, referral to and from hospital, physiological assessment along with scores for assessing the injury severity. Developing a local trauma registry helped us in scrutinising our practice, and we believe that a national or regional trauma registry is the need of the hour in Pakistan. This will highlight the concerns specific to our society in providing quality t...
The developing world shares the paramount proportions of global surgical complications. The surgi... more The developing world shares the paramount proportions of global surgical complications. The surging population grappling with lack of resources and awareness and poor quality healthcare infrastructure are a few of the many factors faced by the population of 2.9 billion people. The charting of data regarding post-surgical complications is deficient and no national average is present for comparison. In this context, the implementation of the US-based ACS-National Surgical Quality Improvement Program (NSQIP) that compares hospital performance on basis of post-surgical complication data provided by the wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To the best of our knowledge, this report is the first from a low-middle income country to report its postoperative neurosurgical complications in comparison with international benchmarks. We hope that with a relatively higher reported rate of surgical complications and mortalities in the developing world, the implementation of the NSQIP program can act as an important catalyst in taking important measures. For a specialty like neurosurgery in particular where the consequences of surgical complications are much higher, NSQIP can perhaps have an even greater impact. In this article, we will provide our hospital's initial experience with NSQIP and will also share the learning points derived from it.
Gastric volvulus is a rare surgical emergency which mostly presents in children and occasionally ... more Gastric volvulus is a rare surgical emergency which mostly presents in children and occasionally in adults. It results due to pathological malrotaion of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and caries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed. Keywords: Gastric Volvulus, Malrotation, Vomiting, Continuous...
Objective: Trauma is the significant non-obstetrical cause of maternal mortality in women aged 35... more Objective: Trauma is the significant non-obstetrical cause of maternal mortality in women aged 35 years or younger. It is expected to complicate around 1 in 12 pregnancies and accounts for 46% of such deaths. In this study, we present our experience of trauma during pregnancy at a tertiary care hospital in Karachi. Methods: A standardized form was used to extract data from online records for all pregnant women who presented with traumatic injuries to the Aga Khan University Hospital from 2014 to 2019. Analysis was performed using SPSS v. 21. Chi-squared tests were performed for comparison of categorical data. Results: A total of 48 pregnant females with a mean age of 28.80 ± 6.50 years were included in this study. Road traffic accidents (RTA) accounted for the commonest cause of injury in the first (66.7%) and second (65%) trimesters. However, fall (45.5%) followed by RTA (27.3%) was the most frequent mechanism of injury during the third trimester. Gunshot injuries were seen in 4 pa...
Introduction Trauma is the leading cause of death among a younger population not only in USA but ... more Introduction Trauma is the leading cause of death among a younger population not only in USA but in Pakistan as well. The high prevalence of disease should result in a larger amount of data and a larger number of publications resulting in the ability to explore improvements in the field. This study aimed to review the trauma literature generated from Pakistan. Methods Journals indexed with PubMed from January 2010 to December 2014 were searched using the search term “Trauma AND Pakistan” filtering for relevant dates and human reports only. The abstracts and articles were reviewed by the authors to collect data on a proforma. Results 114 articles were published from Pakistan during these five years; 64% of articles were published in international journals; 63% of articles were published in journals with an Impact Factor less than 1; 54% of articles were published from one of four provinces of Pakistan; 64% of articles provided Level 4 evidence whilst another 14% of articles provided ...
Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very ... more Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very high mortality. Time is of essence and if not promptly recognised these injuries could have devastating consequences. We report a case emphasising the importance of oesophagoscopy in diagnosing oesophageal injuries. A young man presented to our emergency ward as an unwitnessed road traffic accident after receiving first aid from a secondary care facility. At presentation, he was haemodynamically stable with decreased power in lower limbs, and with severe neck and back pain. There was high suspicion of spinal injury, which was later evident on clinical and on radiological findings. A CT scan revealed oesophageal injury, indicated by contrast extravasation, which was convincing enough to proceed without endoscopy. Surprisingly, the apparently convincing injury picked up on CT scan marked by contrast extravasation turned out to be an artefact, which led to a negative surgical exploration.
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