Efficacy of pregabalin, amitriptyline, and gabapentin for neuropathic pain.

Neuropathic pain largely influences the well-being of patients. Anticonvulsant and antidepressant medications, such as Pregabalin, Gabapentin, and Amitriptyline, are routinely prescribed as initial treatments for neuropathic pain. The study sample has a total of 270 patients who meet the inclusion criteria and are further distributed into three equally sized groups (A, B, and C). Group A was administered with Gabapentine 300mg, Group B with Pregabalin 75 mg, and Amitriptyline 10 mg to Group C. The occurrence of any adverse drug response was documented using the ADR reporting form, while the pain of the patient's post-medication was recorded using a numerical pain rating scale (NPRS). The comparison of the NPRS scores of all three groups "by using ANOVA test" both at baseline and after 15 days reveal that the differences between the three groups are statistically insignificant (p > 0.089). However, after one month of continuous use, the difference becomes slightly significant (I.e., p = 0.003). Gabapentin, pregabalin, and amitriptyline demonstrate similar effectiveness in alleviating neuropathic (NeP) pain. The study concludes that gabapentin is superior to both pregabalin and amitriptyline with fewer adverse effects, leading to improved patient adherence for long-term use.

Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Tranexamic acid is a cost-effective intervention for the prevention of postpartum hemorrhage among women who undergo cesarean delivery, but the evidence to support its use is conflicting. We conducted this meta-analysis to evaluate the efficacy and safety of tranexamic acid in low- and high-risk cesarean deliveries. DATA SOURCES: We searched MEDLINE (via PubMed), Embase, the Cochrane Library, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform portal from inception to April 2022 (updated October 2022 and February 2023) with no language restrictions. In addition, grey literature sources were also explored. STUDY ELIGIBILITY CRITERIA: All randomized controlled trials that investigated the prophylactic use of intravenous tranexamic acid in addition to standard uterotonic agents among women who underwent cesarean deliveries in comparison with a placebo, standard treatment, or prostaglandins were included in this meta-analysis. METHODS: We used the revised Cochrane Risk of Bias tool (RoB 2.0) to assess the quality of the included randomized controlled trials. RevMan 5.4 was used to conduct all statistical analyses using a random-effects model. RESULTS: We included 50 randomized controlled trials (6 in only high-risk patients and 2 with prostaglandins as the comparator) that evaluated tranexamic acid in our meta-analysis. Tranexamic acid reduced the risk for blood loss >1000 mL, the mean total blood loss, and the need for blood transfusion in both low- and high-risk patients. Tranexamic acid was associated with a beneficial effect in the secondary outcomes, including a decline in hemoglobin levels and the need for additional uterotonic agents. Tranexamic acid increased the risk for nonthromboembolic adverse events but, based on limited data, did not increase the incidence of thromboembolic events. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. The quality of evidence was rated as low to very low for outcomes in the low-risk population and moderate for most outcomes in the high-risk subgroup. CONCLUSION: Tranexamic acid may reduce the risk for blood loss in cesarean deliveries with a higher benefit observed in high-risk patients, but the lack of high-quality evidence precludes any strong conclusions. The administration of tranexamic acid before skin incision, but not after cord clamping, was associated with a large benefit. Additional studies, especially in the high-risk population and focused on evaluating the timing of tranexamic acid administration, are needed to confirm or refute these findings.

Frequency of migraine according to the ICHD-3 criteria and its association with sociodemographic and triggering factors in Pakistan: A cross-sectional study.

Background: Migraine is a primary headache disorder marked by episodes of moderate to severe headache that is unilateral, throbbing in character, having a duration of 4 h to three days, and associated with nausea, vomiting, photophobia, and phonophobia. Aims: Our study aims to determine the frequency of migraine in Pakistan, its association with sociodemographic variables and triggering factors, and the coping mechanisms used. Methods: A cross-sectional study was conducted through an online survey from March 19, 2022, to June 15, 2022. The snowball sampling technique was used for data collection. The questions asked included those on sociodemographic information, screening questions, and questions on triggering factors and coping mechanisms. The screening was done using the ICHD-3 criteria and percentages were calculated using SPSS. Results: Of the 986 respondents, 393 suffered from migraine. The majority of them were female (78.1%), belonged to the age group 20-29 years (69.2%), and were students (76.1%). 32.8% of the migraineurs had a family history of migraine. Most frequent triggers included sleep disturbance (70.5%), stress (66.7%) and fatigue (64.4%). Of the female migraineurs, 31.8% had menstruation as a trigger. The coping mechanisms used included taking rest, medication, staying in a quiet and dark place, and doing massage. Conclusion: The findings suggest that young adults, especially females, with a stressful and sleep-deprived lifestyle are more vulnerable to migraine. However, further studies must focus on trigger synergy and interrelation of triggers that precipitate migraine so a better understanding can be developed for the prevention, diagnosis, and treatment of migraine.

Implementation evaluation of a leadership development intervention for improved family experience in a private paediatric care hospital, Pakistan.

BACKGROUND: A study from a tertiary care center in Pakistan demonstrated that a leadership development intervention led to improved family experience of care outcomes. The objective of the current paper is to assess the implementation of this intervention and identify barriers and facilitators to inform sustainability and scalability. METHODS: A working group designed the intervention using a theory-of-change model to strengthen leadership development to achieve greater employee engagement. The interventions included: i) purpose and vision through purpose-driven leadership skills trainings; ii) engaging managers via on-the-job mentorship programme for managers, iii) employee voice i.e., facilitation of upward communication to hear the employees using Facebook group and subsequently inviting them to lead quality improvement (QI) projects; and iv) demonstrating integrity by streamlining actions taken based on routine patient experience data. Implementation outcomes included acceptability, adoption, fidelity across degree & quality of execution and facilitators & barriers to the implementation. Data analyzed included project documentation records and posts on the Facebook group. Analysis indicated acceptability and adoption of the intervention by the employees as178 applications for different QI projects were received. Leadership sessions were delivered to 455 (75%) of the employees and social media communication was effective to engage employees. However, mentorship package was not rolled out nor the streamlined processes for action on patient experience data achieved the desired fidelity. Only 6 QI projects were sustained for at least a year out of the 18 approved by the working group. Facilitators included leadership involvement, real-time recognition and feedback and value-creation through participation by national and international celebrities. Challenges identified were the short length of the intervention and incentives not being institutionalized. The authors conclude that leadership development through short training sessions and on-going communications facilitated by social media were the key processes that helped achieve the outcomes. However, a long-term strategy is needed for individual managerial behaviours to sustain.

Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care.

BACKGROUND: Evidence suggests improvement in nursing staff satisfaction, competence, and retention after implementation of evidence-based mentorship programmes. When guided by a framework of compassion, mentoring as a caring action can not only build healthy, transformative relationships but a similar behavior is reciprocated to patients which subsequently can drive patient experience of care. However, examples of on-job mentorship programs for nurses in low- and middle-income countries (LMIC) are limited. OBJECTIVE: The objective of the study was to develop an on-job nursing mentorship programme using a compassionate framework aimed at improving nurses' experience and thus enhancing patient experience in a tertiary care hospital in Pakistan. METHODS: Designed as an intervention development study, it was completed between January 2018-December 2019. The programme was developed by a team composed of service and nursing leadership, director patient experience of care and a compassion specialist using a theory of change model. The package followed a series of steps, a) identification of a framework, b) creation of working group c) needs assessment and d) multiple meetings to frame the model followed by implementing the preconditions for roll-out of the programme with the frontline staff. RESULTS: The eventual outcome was improving the patient's experience of compassion while the intermediate outcome was to have nurses demonstrate compassionate care. The pre-conditions were identified as: recruitment of staff with appropriate skills for pediatric care, provision of compassionate experience to the frontline nurses by addressing their specific pain points, development of competent head nurses as supervisors and creation of a compassionate culture. To ensure the pre-conditions, various interventions were planned with some implemented through the course of the study while others are in the process of being rolled out. These involved, inclusion of pediatric compassion specific module during orientation of new hires, creation of space to talk about compassionate skills with staff, provision of trainings and mentorship to create competent head nurses, and creating a culture that promoted and recognized compassionate care values. CONCLUSION: The approach helped to delineate feasible pathways for an on-job compassionate mentorship programme enhancing routine supervisors' role as facilitators of compassionate care.

Congenital Central Nervous System Malformations: A Rare Case of an Encephalocele and Literature Review of Its Associations, Imaging Modalities, Radiological Findings, and Treatments.

Congenital central nervous system (CNS) malformations are relatively rare conditions present in fetuses that may result in intrauterine fetal deaths (IUFDs). We report a case of a 42-year-old female who presented at 29 weeks gestation with lack of a fetal heart beat likely due to a congenital malformation resulting in IUFD. This case report and literature review provides a better understanding of the encephalocele as a harbinger for IUFD.

Development and feasibility testing of a play-based psychosocial intervention for reduced patient stress in a pediatric care setting: experiences from Pakistan.

BACKGROUND: Hospitalization can be a source of great stress for children and their families. In high-income countries, there are specialized staff to help children cope using different techniques including play. However, it is a major challenge in low and middle-income countries (LMIC) due to financial constraints and untrained human resource. The objective of study was to develop and test the feasibility and acceptance of a psychology trainee-delivered model postulated on employing play as a means of enhancing child-parent interactions leading to reduced stress during hospitalization. METHODS: This study was conducted in the paediatric ward of a tertiary care private hospital in Pakistan. Pre-intervention survey revealed that parental stress stemmed mainly from seeing their child irritable, distressed, or in pain. Using a theory of change model, a play-based psychosocial intervention was developed to address these factors. The intervention approach was informed by principles of Nurturing Care Framework and play therapy. Children between birth and 6 years admitted in the acute care ward were eligible. The intervention was delivered between March 2019 and December 2020 by psychology trainees who were supervised by a clinical psychologist. The play-based sessions were delivered at the bedside and ranged from 20 to 40 min. Parents receiving the intervention were later interviewed for their stress, child emotions, and feedback about the service using structured surveys administered by psychology graduates. The trainees delivering the intervention were requested to provide their feedback as a written qualitative open-ended narrative. These narratives were analyzed using an inductive approach. RESULTS: The survey was conducted with 223 families with about half of the sample having children under 2 years of age. Forty-five percent of parents reported play intervention to be one of 3 key factors in improving their experience during hospital stay. Only 5% of parents reported feeling stressed about the child illness after the intervention. Ninety to 96% parents felt respected, listened to, and understood by the therapists. Thematic analysis of the feedback by trainees indicated the internship to be a useful experience and a new avenue for professional life whereas physicians appreciated the interventions. CONCLUSIONS: The authors conclude that psychology trainees can feasibly deliver a play-based intervention under supervision for reduced stress in children and their parents during hospitalization with mutual benefits.

To determine the efficacy of bilateral inferior petrosal sinus sampling in differentiating Cushing disease from ectopic Cushing syndrome.

Management of endogenous Cushing syndrome is based on its aetiology. Increased Adrenocorticotropic Hormone (ACTH) levels are the most common cause of this disorder and, therefore, it is critical to determine the source of ACTH before further management. Dynamic post contrast MRI is currently the most common investigation implied to diagnose pituitary adenoma; however, it comes with the drawback of low specificity and high false positive results. Inferior petrosal sinus sampling (IPSS) is an established invasive procedure performed to differentiate central versus peripheral source of ACTH which, in turn, results in hypercortesolaemia. This is a series of 14 patients who underwent IPSS at the Department of Radiology, Aga Khan University Hospital, Karachi, from January 2006 to December 2018. The case series emphasises the role of IPSS in the management of ACTH-dependent Cushing syndrome and combined efficacy of Dynamic post-contrast MRI and the procedure under focus.

Challenges in diagnosis of disease reported 100 years back: Cushing syndrome; recent advances.

Treatment of Cushing syndrome depends on diagnosis of etiology responsible for hypercortisolism in the body, which sometimes presents with a challenge. Inferior petrosal sinus sampling for ACTH levels, followed by peripheral venous sampling is a proven tool to be a gold standard for differentiating between peripheral and central cause of ACTH dependent Cushing syndrome. This case report is of an elderly female who presented as an outpatient in the endocrinology clinic of Aga Khan university hospital on 22/6/2017 with clinical features of hypercortisolism. After workup she was found to have cushing syndrome secondary to ACTH secreting bronchial carcinoid tumour.

Maternal morbidity in emergency versus elective caesarean section at a tertiary care hospital.

BACKGROUND: In the past 30 years the rate of caesarean section (C/S) has steadily increased from 5% to more than 20% for many avoidable and unavoidable indications. The objective of this study was to compare maternal morbidity and determine its cause in elective and emergency caesarean section. METHOD: It was a cross-sectional comparative study conducted in Civil Hospital Karachi at Obs/Gyn Unit III. All mothers admitted through OPD or emergency during the study period, of any age or parity undergoing C/S were recruited in the study. Patients having previous myomectomy, hysterotomy or classical C/S were excluded from the study. Patients undergoing emergency C/S were placed in group A, and those delivered by elective C/S were included in group B. Study variables were general and obstetric parameters and complications observed intra-operatively. Any postoperative complications were recorded from recovery room till patient was discharged from the ward. RESULTS: There were 50 patients in each group. In group A, 11 (22%) were booked and 33 (66%) were referred cases. In group B, 48 (96%) were booked. The mean age in both groups was 28 years. In both groups, multigravida compared to primigravida were 78% vs 22% in group A, and 92% vs 8% in group B. Indication for C/S was previous C/S in 10 (20%) patients in group A, and 39 (78%) patients in group B, placenta previa, chorioamionitis, obstructed labour (6, 12% each); pregnancy induced hypertension and eclampsia in 5 (10%) cases in group A only. Intra-operative complications in group A were 48 (96%) vs 15 (30%) in group B (p = 0.000). Postoperative morbidity in group A was 50 (100%) and 26 (52%) in group B (p = 0.000). Intra-operative complication was haemorrhage in 46 (92%) cases in group A and 11 (22%) in group B. Anaesthetic complications were 40 (80%); prolonged intubation 25 (50%), aspiration of gastric contents 8 (16%), and difficult intubation 7 (14%) in group A. Ten (20%) cases had anaesthetic complications in group B. Commonest postoperative complication in both groups was anaemia in 41 (82%) and 11 (22%) cases respectively. CONCLUSION: Maternal morbidity is significantly higher in emergency C/S. Haemorrhage is a frequent complication in C/S, emergency or elective.

Socio-demographic characteristics and the three delays of maternal mortality.

OBJECTIVE: To describe the socio-demographic characteristics and the three delays of maternal mortality in a tertiary teaching hospital. STUDY DESIGN: Retrospective, observational study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology, Unit III, Civil Hospital, Karachi, from April 2005 to May 2008. METHODOLOGY: One hundred and four consecutive maternal deaths were reviewed. Data regarding age, parity, sociodemographic characteristics, booking status, referral source, cause of death and the three delays was collected on structured proformas, analyzed by the statistical software, SPSS version 13, and presented in the form of frequencies and percentages. RESULTS: The projected maternal mortality ratio was 1650/100,000 live births. The mean age was 28+/-6.2 years and median parity was two. Seventy-one women (68%) were uneducated, 65 (62.5%) belonged to lower socioeconomic class and 60 (58%) had received no antenatal care. Ninety-eight women (94%) had one or more delays, with 70 (71%) having the first delay, 73 (74%) having the second delay and 47 (48%) the third delay. The most frequent reasons for first, second and third delays were lack of awareness in 88.5% women, long distance in 39.7% women and difficulty in getting blood in 49% women respectively. CONCLUSION: The very high maternal mortality ratio suggests lack of access of women to quality healthcare facilities. A majority of these women suffered first and second delays in their management, which could be due to their poor sociodemographic factors.

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.

BACKGROUND: The outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak. METHODS: Questionnaires were distributed to all willing employees of Sunnybrook and Women's College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12). RESULTS: Of the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family's health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6-9.6), living with children (adjusted OR 1.8, 95% CI 1.5-2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5-4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2-2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5-5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2-5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4-3.5) and ability to do one's job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9-4.6). INTERPRETATION: Our findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.