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Background Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. The “Critical Care Pain Observation Tool (CPOT)” is a reliable and validated objective assessment tool for those patients who cannot self-report pain in ICU. The objectives of the educational course were to assess the baseline knowledge, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test. Methods The educational course of six hours of contact time on the use of CPOT for pain assessment in ICU patients was designed and conducted by the authors after approval from the Ethics Review Committee, Aga Khan University. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan. A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge, and practice of participants regarding pain assessment in critically ill patients and the same test was taken at the end of the course. Results A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belong to the metropolitan city (p = 0.010). In multivariate analysis, participants from non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038). Conclusions The participating physicians and nurses showed a positive impact on the knowledge and clinical skills regarding pain assessment in CIPs. The participants from hospitals in metropolitan cities showed a significant improvement over those who were from non-metropolitan cities.

Background: Regular on‐the‐job training and educational courses may improve nurses’ knowledge and practice regarding pain assessment and initial treatment. Objectives: To assess the impact of a newly developed educational course in terms of improvement in knowledge regarding pain assessment and initial treatment by using pretest and posttest multiple‐choice question scores and to determine the retention of knowledge 3 months after the educational course and perceived change in clinical practices among nurses working in adult surgical and medical wards at the Aga Khan University Hospital. Methods: After getting approval from the institutional review committee, an education course was developed and conducted. A total of 86 participants attended both online and physical components. Teaching methodologies included online lectures, small group tutorials and hands‐on workshops using demonstrations of locally developed videos. Pretests and posttests were conducted to assess the knowledge. All participants were requested to complete an online questionnaire to know the impact of the course on their clinical practice. Results: Eighty‐six participants completed the course, of which 52 (60.5%) were female and 34 (39.5%) were male. The mean difference between the pretest and posttest scores of participants was 4.72 (39.66%), which was statistically significant ( p ≤ 0.001). The mean posttest multiple‐choice question score of participants was 16.70 ± 3.56, and the mean posttest multiple‐choice question score of participants after 3 months was 15.60 ± 4.09 with a mean difference of 1.10 (6.59%), which was not statistically significant ( p = 0.121). Conclusion: The hybrid educational course had a significant learning impact on the knowledge of participants and their clinical practice.

Background and Aims: Assessment of patient satisfaction is an important tool for monitoring the quality of care in hospitals. The aim of this survey was to develop a reliable tool to assess patient satisfaction with acute pain management service (APMS) and identify variables affecting this so that care can be improved. Methods: A questionnaire was developed and administered to  patients after being discharged from APMS care by an unbiased person. Data collected from record included patient demographics, surgical procedure, analgesic modality, co-analgesics and dynamic and static pain scores. Questions included pain expected and pain experienced, APMS response time, quality of pain relief with treatment, professionalism of APMS team, overall experience of pain relief and choosing/suggesting same modality for themselves/family/friends again. Five-point Likert scale was used for most of the options. Statistical analysis was done using SPSS 19. Results: Frequency and percentages were computed for qualitative observation and presented on pie chart and histogram. Seventy-one per cent patients expected severe pain while 43% actually experienced it. About 79.4% would choose same analgesia modality in future for self/family/friends. Ninety-nine per cent found APMS staff courteous and professional. About 89% rated their experience of pain management as excellent to very good. Conclusion: The survey of patients′ satisfaction to monitor the quality of care provided by APMS provided positive inputs on its role. This also helps to identify areas requiring improvement in care and as a tool to gauge the quality of care.

Background Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade. Methods A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria. Results Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia. Conclusion We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

Objective: To assess the accuracy of portal vein pulsatility (VPI) for non-invasive diagnosis of high-risk non-alcoholic fatty liver disease (NAFLD). Study Design: Cross-sectional study. Place and Duration of Study: Pakistan Institute of Medical Science, Islamabad Pakistan, from Jan to May 2022. Methodology: Duplex Doppler ultrasound was used to examine the main portal vein in patients with a biopsy-proven Nonalcoholic fatty liver disease (NAFLD) diagnosis. Patients were evaluated by Doppler ultrasonography after fasting for four hours in accordance with standard methodology. The maximum (Vmax) and minimum (Vmin) blood velocities in the portal veins were measured using the spectral waveform. Results: Out of 240 NAFLD patients, 102(42.50%) were males, and 138(57.50 %) were females. According to the Non-alcoholic Steatohepatitis clinical research network (NASH CRN) scoring system, 95(39.58%) patients had F0 disease, 80(33.33%) had F1, 30(12.5%) patients F2, 24(10%) patients had F3 and 11(4.58%) had F4. 50(53.76%) patients in the low-risk group and 43(46.24%) patients in the high-risk group had diabetes. Of 102 males, 73(71.56%) had low risk, and 29(28.44%) had high risk. While out of 138 females, 79(57.24%) females had low risk, and 59(42.76%) females had a high risk of NAFLD. Venous pulsatility index, NAFLD fibrosis score, FIB-4, BARD score, and APRL had statistically significant differences (p<0.05). Conclusion: Venous pulsatility index is a reliable marker for detecting high-risk NAFLD. It is a readily available non-invasive investigation and can be reliably used as a screening tool for detecting NAFLD in high-risk patients, avoiding invasive investigation.

Objective: To evaluate the renal resistive index (RI) and serum creatinine correlation in patients with diabetic nephropathy. Study Design: Cross-sectional study Place and Duration of Study: Department of Radiology, Pakistan Institute of Medical Sciences, Islamabad Pakistan, from Nov 2020 to Apr 2021. Methodology: This study was conducted on 80 patients. Doppler renal artery sonography was carried out, and for all the individuals with controlled blood pressure, gender, age, urinary protein, serum creatinine and HBA1c were recorded. Results: In our study, 42(52%) patients were females, whereas the remaining 38(48%) were males. The mean age was observed to be 49.15±11.91 years. A significant positive correlation (r=0.53) was found between Resistive Index and Serum Creatinine.The correlation co-efficient values between Resistive Index and Serum Creatinine in female and male patients were r=0.58 and r=0.47, respectively. Conclusion: The present study concluded that RI had no significant statistical correlation with albuminuria, proteinuria and HbA1c levels. However, a statistical correlation between RI and creatinine level was reported.

Objective: To assess the role played by ultrasound in evaluating plantar fasciitis and associate the findings with Magnetic resonance imaging. Study Design: Case series. Place and Duration of Study: Department of Radiology, Pakistan Institute of Medical Sciences, Islamabad Pakistan, from Nov 2020 to Apr 2021. Methodology: All the patients underwent ultrasonography and magnetic resonance imaging scanning. The study and control Groups consisted of 38 patients. Results: Out of 38 patients, plantar fascia thickness in symptomatic feet was measured with ultrasound for both the Study and Control Groups. The Control Group had slightly thinner plantar fasciitis (1.1-2.4 mm, 1.7 ± 0.06 mm; p =0.03) compared to the Study Group (2.9-6.9 mm; 4.9±1.4 mm). In addition, this study compared other plantar fasciitis diagnostic signs on sonography with the magnetic resonance imaging findings. The diagnostic accuracy of plantar fascia pathological focal echogenicity, plantar fascia oedema, perifascial oedema, and plantar fascia rupture was 15(80.6%), 12(60.7%), 15(77.1%), and 13(68.6%) respectively. The diagnostic accuracy of ultrasonography was lower while evaluating for calcaneal spurs. Conclusion: The present study concluded that ultrasonography could be the basic initial diagnostic imaging modality to confirm clinically suspected cases of plantar fasciitis. However, magnetic resonance imaging could be the preferred diagnostic modality for suspected complex pathology and lack of clinical presentation.

Objective To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. Results Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients’ other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.

Application of tourniquet during orthopaedic procedures causes pain and increase in blood pressure despite adequate anaesthesia and analgesia. In this study, we compared ketorolac with ketamine in patients undergoing elective lower limb surgery with tourniquet in order to discover if ketorolac was equally effective or better than ketamine in preventing tourniquet-induced hypertension. Approval was granted by the Institutional Ethics Review Committee and informed consent was obtained from all participants. A randomised double-blinded controlled trial with 38 patients each in the ketamine and ketorolac groups undergoing elective knee surgery for anterior cruciate ligament repair or reconstruction was conducted. Induction and maintenance of anaesthesia were standardised in all patients, and the minimum alveolar concentration of isoflurane was maintained at 1.2 throughout the study period. One group received ketamine in a dose of 0.25 mg/kg and the other group received 30 mg ketorolac 10 min before tourniquet inflation. Blood pressure was recorded before induction of anaesthesia (baseline) and at 0, 10, 20, 30, 40, 50, and 60 min after tourniquet inflation. The demographic and anaesthetic characteristics were similar in the two groups. At 0 and 10 min, tourniquet-induced rise in blood pressure was not observed in both groups. From 20 min onward, both systolic and diastolic blood pressures were significantly higher in ketorolac group compared to ketamine group. We conclude that ketamine is superior to ketorolac in preventing tourniquet-induced increases in blood pressure.

Research has shown that more than 50% of patients have insufficient postoperative pain relief despite the use of multiple pain management modalities. Insufficient pain relief leads to several pathophysiological effects. One of the barriers to optimal pain relief is patient's lack of knowledge regarding the options available for pain management and their potential side effects. In this survey, we evaluated surgical patients' knowledge about postoperative pain and its management in patients undergoing major upper abdominal surgeries at a tertiary care hospital. This was a cross-sectional survey. A total of 155 patients (18-60 years of age) scheduled to undergo elective major upper abdominal surgery were included after ethical approval and informed consent. Preoperatively, patients were interviewed through a questionnaire regarding knowledge about postoperative pain and its management. The average age of the patients was 42.97 ± 13.05 years. Excellent and good knowledge were observed in 11.61% and 21.94% patients, respectively, whereas fair and poor knowledge were seen in 42.58% and 23.87%, respectively. Inadequate knowledge was more marked regarding analgesic side effects and addiction risk. Education level, history of surgery, and adequate information provision about pain management plan by surgeons preoperatively were significantly associated with a higher level of knowledge about pain and its management (p-value 0.0005, 0.002, and 0.0005, respectively). A considerable proportion of patients have inadequate knowledge about their postoperative pain and its management, particularly in areas of side effects and addiction risk.