Komal Abdul Rahim

Background: Older patients experience poorer outcomes due to factors such as frailty and comorbidities. This study examines the long‐term outcomes of injured older adult patients, focusing on trauma‐related quality of life (QoL) and functional independence in low‐ and middle‐income countries such as Pakistan. Methods: This prospective cohort included patients aged ≥ 60 admitted to two tertiary care hospitals in Karachi, Pakistan, between December 2021 and May 2023. Functional Independence Measure (FIM) and Revised Trauma‐related Quality of Life (RT‐QoL) scores were recorded at 1‐, 3‐, and 6‐month post‐discharge. Linear regression and an adjusted cumulative link model were used to evaluate factors affecting FIM and RT‐QoL at 6 months. Results: Of 3374 trauma admissions, 651 patients were aged ≥ 60 years; 288 who were alive at 6 months with follow‐up data were analyzed (mean age 69.1 years, 54% male); injuries were predominantly due to falls (69.1%) and involved extremities (72%). Age (−0.58 per year; −0.85 to −0.31) and road traffic incidents (5.59; 0.39–10.79) were associated with FIM scores at 6 months. Most patients (85%) reached modified to complete independence by 6 months. Most recovery was seen in emotional well‐being, slightly higher in females as compared to males (65.1% vs. 62.8%). There was a significant difference in recovery between females and males in functional engagement at 1 month (14.5% vs. 29.5%, p < 0.05) and 6 months (43.9% vs. 62.2%, p < 0.05). Conclusion: Older adult trauma patients who survived to 6 months largely recovered toward their pre‐injury level of functional independence, though residual disability was common and females showed lower functional engagement. High mortality among severely injured patients likely skewed results toward milder injuries. These findings underscore the need for both injury prevention and trauma system strengthening to reduce mortality, and rehabilitation services to address residual disability among survivors.

Introduction: Healthcare financing models significantly impact health outcomes across many diseases in high‐income countries (HICs). In low or middle‐income countries (LMICs), where financial vulnerabilities are much higher, little is known about the relationship between payment mechanisms and emergency care outcomes. This study aimed to quantify the association between trauma care payment mechanisms and inpatient mortality. Methods: We conducted analysis of data from in four facilities in province Sindh, Pakistan (two urban and two rural sites) collected between May 2023 and February 2025. The outcomes were inpatient mortality and length of stay (LOS). We compared patients with out‐of‐pocket (OOP) expenses with no‐OOP. We calculated adjusted odds ratio with a 95% confidence interval for OOP after controlling for age, sex, injury severity (Kampala Trauma Score [KTS]), blood transfusion, procedure, comorbidity, and setting. We also applied propensity score matching (PSM) on age, sex, mechanism of injury, injury severity (KTS), and setting. Results: Most of the 3572 enrolled patients were young (median age 35 years and IQR 25–50) males (81.95%) and a third paid OOP for hospital care ( n = 978 and 37.38%). The overall mortality rate was 4.85%, with a significantly higher mortality rate among the OOP group compared to the no‐OOP group (10.02% vs. 2.89%; AOR 3.14: 95% CI 1.93, 5.10). Additionally, the hospital LOS (median 4 vs. 9 days and p value < 0.001) and mean survival time of patients (22.81 days vs. 28.67 and p value < 0.001) were lower for the OOP group than no‐OOP group. The odds ratio after PSM showed a weak significant independent association between OOP and mortality (OR 1.05; 95% CI 1.02, 1.08). Conclusion: Patients who paid OOP for injury care had greater mortality, suggesting that alternative financing strategies could improve outcomes in LMICs. Additionally, OOP was associated with shorter LOS, highlighting the need to improve universal health coverage for complete injury care.

Background Low- and middle-income countries (LMICs) face a high burden of trauma-related deaths, yet lack prospective, standardized data to guide care. In Pakistan, in-hospital trauma management and outcomes remain poorly documented. Purpose The aim of this study was to examine injury epidemiology, post-emergency department care, and hospital outcomes using a pilot digital trauma registry in Pakistan. Methods This study was conducted from December 2021 to February 2023 at two leading tertiary care hospitals in Karachi, Pakistan. We included all admitted adult trauma patients (≥ 18 years). We prospectively collected data on demographics, injury details, inter-hospital case management, in-hospital care, and discharge outcomes. Results A total of 3,087 patients were enrolled, mostly male (79.82%), with 24.33% under 25 years old and 42.38% of Muhajir ethnicity. Road traffic injuries (RTIs) (56.43%), primarily amongst riders of two-wheelers (56.74%), were the leading cause, of whom only 8.66% wore helmets. Most arrived by ambulance (77.12%), and one third (33.66%) were transferred from another hospital. Extremity (55.17%) and head/neck injuries (41.72%) were most common. Severe injuries (ISS > 15) were seen in 30.26%, while 90.86% had a GCS > 12. X-rays (92.81%), CT scans (56.04%), and ultrasounds (16.55%) were common investigations. Surgery was performed in 50.28% of cases. The in-hospital mortality rate was 15.10%, and the median length of stay (LOS) was five days. Conclusion Our findings show high in-hospital trauma mortality, often among patients transferred from other facilities, emphasizing the role of timely care. This study highlights the potential of trauma registries to inform preventive policies and clinical care, particularly in low-income settings.

Context: Wasting is a key indicator of child survival and well-being. Enhancing practices related to infant and young child feeding (IYCF) is a suggested strategy to mitigate mortality risks and enhance nutritional conditions associated with wasting. Interventions centered on behavioral modifications through IYCF counseling hold promise in increasing the effectiveness of IYCF practices. Objective: In this review we sought to study the impact of intensive IYCF counseling interventions for preventing wasting and nutritional edema among infants and children up to 5 years of age. Data Sources: We searched 9 electronic databases for articles published up to July 2021, and conducted an updated search on Ovid MEDLINE and MEDLINE for articles published until April 13, 2023. Randomized controlled trials (RCTs) were included in the review. Data Extraction: Two review authors independently assessed the search results, extracted data, and evaluated the risk of bias. Data Analysis: Our outcomes included prevalence of wasting and underweight, deterioration to severe wasting, anthropometric outcomes (weight-for-height z-score, weight-for-age z-score) and child morbidity and mortality. We summarized the findings of this review for primary outcomes according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. A total of 10 studies from 17 records were found to be eligible for inclusion, and all of these studies were meta-analyzed. Evidence suggests that compared to controls, IYCF counseling is likely to have little to no impact on the prevalence of wasting (relative risk [RR], 0.93; 95% CI, 0.83-1.04; 10 studies; GRADE: moderate). Intensive IYCF counseling had little to no impact on WHZ, MUAC, or WAZ and had an uncertain impact on the prevalence of diarrhea, fever, cough, and underweight (RR, 0.83; 95% CI, 0.70-0.97; 8 studies; GRADE: very low). Conclusion: Nutrition education and counseling showed uncertain GRADE evidence on reducing prevalence of underweight but had no association with wasting. The findings of this review warrant further studies to investigate the impact of IYCF counseling on child morbidity. Systematic Review Registration: PROSPERO registration No. CRD42021277429

Background: Trainee turnover in hospitals with induction of new, less experienced residents and changeover in the clinical teams has been considered an essential factor for increased morbidity and mortality. In high‐income countries (HICs), this is known as the July effect—the time for new inductees. We aim to study the January effect (time of new inductees in our setting) and patient outcomes in an Emergency General Surgery (EGS) cohort. Methods: We used secondary data from adult patients with EGS diagnosis from a tertiary care center in Pakistan (2010–2019). The outcomes of interest were severe adverse events (SAEs), inpatient mortality, length of stay [LOS], and failure to rescue (FTR). Multiple logistic and linear regressions was performed to assess their association. Results: Of the 32,280 patients analyzed, 7.94% were admitted in January. There was significantly higher elective admission (61.06% vs. 53.51%) and surgical interventions (74.80% vs. 72.92%) in January compared to other months. Inpatient mortality, SAEs, FTRs, and LOS did not significantly differ between the two groups. Multivariable analysis showed no significant association of January admission with SAE (AOR 1.06; 95% CI 0.97–1.16), inpatient mortality (AOR 1.09; 95% CI 0.83–1.43), FTR (AOR 1.04; 95% CI 0.78–1.38), and LOS ( β 0.12; 95% CI −0.05–0.29). Conclusion: The results of the study, which has no evidence of the January effect for EGS patients, suggest that this effect is not universally applicable, necessitating context‐specific evaluation to understand the temporal trends in the overall health outcomes of the admitted patients.

Background: Comorbidity has a detrimental impact on Emergency General Surgery (EGS) outcomes. In lesser-developed countries with inconsistent documentation of comorbid conditions, undiagnosed and progressively worsening comorbidities can worsen EGS outcomes. We aimed to discern the comorbidity index as a predictor of complications and inpatient mortality in EGS using a large South Asian sample population.Materials and methods: Data of adult patients with AAST-defined EGS diagnoses at primary index admission from 2010 to 2019 were retrieved. Patients were categorized into predefined EGS groups using ICD-9 CM codes. Primary exposure was comorbidity using the Charlson Comorbidity Index (CCI). The primary outcome was inpatient mortality, and the secondary outcome was complication status. Multiple logistic and Cox regression with Weibull distribution was performed.Results: Analysis of 32 280 patients showed a mean age of 40.06±16.87 years. Overall comorbidity, inpatient mortality, and complication rates were 44.6%, 2.42% and 36.37%, respectively. Patients with moderate CCI had the highest complications (AOR 6.61, 95% CI 5.91, 7.37), and severe comorbidity had the highest hazards (AOR 3.79, 95% CI 2.89, 4.98). Male gender, increasing age, emergent admission status, and lack of insurance were associated with moderate and severe CCI, resulting in prolonged length of stay (5.72 and 5.83 days), reduced survival time (20.04 and 21.95 days), and higher mortality rates (10.52% and 9.48%).Conclusions: We identified predictive patient-level factors associated with higher CCI and worse EGS outcomes. Our findings can help stratify population subsets at risk of worse outcomes, provide valuable insight into disease progression, and aid decision-making in EGS patients.Level of Evidence: III

Background: Trauma is a significant cause of morbidity and mortality, disproportionately affecting low‐ and middle‐income countries (LMICs). Data from high‐income countries (HIC) show an evolution of Trunkey's trimodal distribution of at‐scene, first 48 h and after 7 days mortality to bimodal distribution caused by the flattening of the third peak. The mortality distribution in LMICs is not well described. This paper aims to temporally characterize in‐patient trauma‐related deaths and identify predictors of this mortality among adults in Pakistan. Methods: Data from December 2021 to February 2023 were extracted from a multicenter, prospective trauma registry in Karachi, Pakistan. Data on demographics, injury details including injury severity scores (ISS), inhospital care, and outcomes for admitted adult (≥ 18 years) patients not referred from another facility were extracted. The primary outcome was in‐patient mortality categorized as within 48 h, after 48 h but within 7 days and after 7 days of injury. Multivariable analyses were done using multiple cox‐regression to assess the association of patient and injury characteristics with early (< 48 h) and late mortality (> 48 h). Results: We enrolled 1596 patients. The majority were males (80.70%), aged 18–40 years (55.33%). Half of the patients were admitted with moderate ISS (45.49%). Of these, 293 died (18.36%). Deaths were mainly due to road traffic crashes (66.55%) and head injury (84.98%). An equal proportion of mortality was observed in the < 48 h and day 2–7 groups. One vague mortality peak was also identified at > 7 days ( n = 115). The adjusted hazard ratio for early mortality was 15% higher (95% CI 1.13, 1.18) for every one‐unit increase in the ISS score. The presence of multiple co‐morbidities (AHR = 4.95 95% CI 1.31, 18.68) and head injury (AHR = 15.25 95% CI 3.82, 60.81) were associated with late mortality. Conclusions: In conclusion, our trauma mortality pattern aligns partially with Trunkey's 1983 trimodal distribution, showing a persistent late mortality attributed to deaths from complications. This highlights an urgent need for improvements in trauma care to reduce late‐stage mortality. Further in‐depth analysis is required to understand the underlying mortality drivers among admitted patients.

Background: Surgical site infections (SSIs) are a major cause of increased morbidity, hospital stay, care costs, and mortality in surgical patients; these can be prognosticated by the Charlson Comorbidity Index (CCI) and accounting for age—the Charlson-Age Comorbidity Index (CACI). Given the limited use of CCI/CACI in low- and middle-income countries, we aimed to assess the use of CCI/CACI in prognosticating the 30-day incidence of SSIs among exploratory laparotomy patients at a tertiary care center in Pakistan. Methods: The study analyzed data from adult patients with International Classification of Diseases-9 CM primary index procedure codes for exploratory laparotomy at a tertiary teaching hospital between 2010 and 2019. The primary exposure was categorized into mild (score 1–2), moderate (score 3–4), and severe (score >5) based on CCI/CACI. The outcome of interest was the incidence of SSIs, where days after operation were restricted to 30 days or less within a hospital stay. Adjusted ORs (AOR) with 95% CI are reported using multiple logistic regression. Results: Out of 2,267 exploratory laparotomy patients, 54.43% were classified as having comorbidity. There was no difference noted in the incidence of SSIs among no CACI (15.88%) and patients with mild, moderate, and severe CACI (18.49%, 18.94%, and 17.42%). Effect modification showed that, among females, CCI/CACI was not significantly associated with SSIs but showed a significant association in males. Among males, a dose-response relationship was observed, with severe CACI having the highest odds of developing SSIs (AOR 2.04; 95% CI 1.35 to 3.05) compared with patients with no CACI. Subgroup analysis yielded similar results (AOR 2.03; 95% CI 1.28 to 3.21). Conclusion: Findings suggested that the comorbidity index is valuable in prognosticating surgical outcomes in exploratory laparotomy patients among males, with age being an integral part of the index. CACI should be calculated for risk stratification and management purposes in male patients undergoing exploratory laparotomy. Level of evidence: III