Practices and perceived barriers regarding pain management among Emergency Department physicians: a nationwide multicenter survey in Moroccan hospitals.

Aim: To describe pain management practices in Moroccan emergency departments, and to identify perceived barriers among emergency department physicians regarding pain management. Methods: Eleven Moroccan emergency departments participated in the study. A nationwide survey was administered to physicians. The questionnaire covered physicians' characteristics, practices regarding pain management, and the perceived barriers to pain control. Results: A total of 86 questionnaires were analyzed. The participants' mean age was 41±7 years and 59.3% had more than 10 years working experience in emergency departments. The majority of participants were general physicians (87.2%) with no pain education (73.3%). Pain assessment in emergency departments was carried out by 59.3% of the physicians. Simple interrogatory assessment was the main tool (88.3%) with poor use of algometric scales (11.7%). Pain assessment results were not recorded in clinical charts in 93% of cases. Pain reassessment after treatment was carried out by 23.2% of respondents. Physicians had opiophobia in 80.2% of cases. None of the Moroccan emergency departments participating in the study have a written protocol for pain management. Barriers relating to medical staff and the health care system were the most commonly encountered hindrances that preclude emergency department physicians from proper pain management. Conclusions: Despite the availability of international guidelines, pain management practices are still sub-optimal in Moroccan emergency departments.

Factors associated to unrelieved pain in a Morrocan Emergency Department.

BACKGROUND: In the light of the impact that pain has on patients, emergency department (ED) physicians need to be well versed in its management, particularly in its acute presentation. The goal of the present study was to evaluate the prevalence of unrelieved acute pain during ED stay in a Moroccan ED, and to identify risk factors of unrelieved pain. METHODS: Prospective survey of patients admitted to the emergency department of Ibn Sina teaching university hospital in Rabat (Morocco). All patients with acute pain over a period of 10 days, 24 hours each day were included. From each patient, demographic and clinical data, pain characteristics, information concerning pain management, outcomes, and length of stay were collected. Pain intensity was evaluated both on arrival and before discharge using Numerical Rating Scale (NRS). Comparison between patient with relieved and unrelieved pain, and factors associated with unrelieved pain were analyzed using stepwise forward logistic regression. RESULTS: Among 305 patients who complained of acute pain, we found high levels of intense to severe pain at ED arrival (91.1%). Pain intensity decreased at discharge (46.9%). Unrelieved pain was assessed in 24.3% of cases. Patients with unrelieved pain were frequently accompanied (82.4% vs 67.1%, p = 0.012), and more admitted daily than night (8 am-20 pm: 78.4% vs 64.9%; 21 pm-7 am: 21.6% vs 35.1%, p = 0.031), and complained chiefly of pain less requently (56.8% vs 78.8%, p<0.001). They had progressive pain (73% vs 44.2%, p<0.001), and had a longer duration of pain before ED arrival (72-168 h: 36.5% vs 16.9%; >168 h: 25.5% vs 17.7%, p<0.001). In multivariate analysis, predictor factors of unrelieved pain were: accompanied patients (OR = 2.72, 95% CI = 1.28- 5.76, p = 0.009), pain as chief complaint (OR = 2.32, 95% CI = 1,25-4.31, p = 0.007), cephalic site of pain (OR = 6.28, 95% CI = 2.26-17.46, p<0.001), duration of pain before admission more than 72 hours (72-168 h (OR = 7.85, 95% CI = 3.13-25.30, p = 0.001), and >168 h (OR = 4.55, 95% CI = 1.77-14.90, p = 0.02). CONCLUSION: This study reported high levels of intense to severe pain at ED arrival. However, one quarter patients felt on discharge from the ED that their pain had not been relieved. The relief of pain in ED depend both sociodemographic, clinical, and pain characteristics factors.

Patient satisfaction in a Moroccan emergency department.

BACKGROUND: Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. Currently, research is interested to the satisfaction in several areas, and in various cultures. The aim of this study was; to confirm the reliability and validity of the Arabic version of the Emergency Department Quality Study (EDQS), to evaluate patient satisfaction with emergency care, and to determine associated factors with patient satisfaction. METHODS: A survey of socio demographic, visit and health characteristics of patients, conducted in emergency department (ED) of a Moroccan University Hospital during 1 week in February 2009. The EDQS was performed with patients who were discharged from ED. The psychometric properties of the EDQS were tested. Factors influencing patient satisfaction were identified using ordinal logistic regression. RESULTS: A total of 212 patients were enrolled. The Arabic version of the EDQS showed excellent reliability and validity. Sixty six percent of participants were satisfied with overall care, and 69.8% would return to our unit. The most patient-reported problems were about waiting time and test results. Variables associated with greater satisfaction with ED care were: emergent (OR: 0.15; 95% CI = 0.04-0.31; P < 0.001), or urgent patients (OR: 0.35; 95% CI = 0.15-0.86; P = 0.02) compared to non-urgent patients, and waiting time less than 15 min (OR: 0.41; 95% CI = 0.23-0.75; P = 0.003). Variables associated with lesser satisfaction were: distance patient's home hospital ≤10Kilometers (OR: 2.64; 95% CI = 1.53-4.53; P < 0.001), weekday's admissions (OR: 2.66; 95% CI = 1.32 to 5.34; P < 0.006), and educational level; with secondary (OR: 5.19; 95% CI = 2.04-13.21; P < 0.001) primary (OR: 3.04; 95% CI = 1.10-8.04; P = 0.03) and illiterate patients (OR: 2.53; 95% CI = 1.02-6.30; P = 0.03) were less satisfied compared to those with high educational level. CONCLUSION: Medical staff needs to consider different interactions between those predictive factors in order to develop some supportive tools.

[Bilateral non-secreting adrenal cortical adenoma ]. / Cortico-surrénalome bilatéral non sécrétant.

Non-secreting malignant adrenal cortical adenoma is rare and the bilateral form is exceptional. Diagnosis is often delayed and it has a very poor prognosis. The authors report a case of bilateral adrenal cortical adenoma in a 53-year-old man.

[Clear cell sarcoma of the kidney: 3 case reports]. / Sarcome à cellules claires du rein (à propos de trois observations).

UNLABELLED: Clear cell carcoma of the kidney is a distinct, highly malignant pediatric neoplasm. Its occurrence in adults is extremely rare and the subject of isolated case reports. MATERIAL AND METHODS: We report 3 cases of clear cell sarcoma of the kidney in one men and two women between 23 and 65 years old (mean age is 40 years). A radical nephrectomy with hilar lympgh node dissection was accomplished. A combination chemotherapy regiment (cisplatin and doxorubicin) was performed on 6 cycles in 1 case. The other 2 case was not underwent chemotherapy or radiation. RESULTS: In the patient underwent the combination chemotherapy there was not evidence of tumor in the abdomen and thorax on CT Scan 4 years later. In one of the two patient not underwent chemotherapy or radiation, the CT scan revealed a left psoas reccurrence three month later; therapy consisted for surgery without chemotherapy or radiation. Four month later, tfe CT scan revealed a reccurrence in the left retroperitoneal region and liver and speen metastasis. The patient was dead two month later. The other patient not underwent chemotherapy or radiation was dead seven month after nephrectomy. CONCLUSION: Optimal treatment is unknown, and surgery; radiotherapy and chemotherapy are used alone but mostly in combination.

[Vesicosphincteric disorders and neurosyphilis]. / Troubles vésico-sphinctériens et neuro-syphilis.

Voiding disorders secondary to neurosyphilis have now become rare. The authors report a case of a patient with arthritis of the knee associated with dysuria and chronic urinary retention. Urethrocystography showed a large bladder with post-voiding residual urine. Urodynamic assessment revealed detrusor areflexia. The aetiological diagnosis was neurosyphilis. Serological tests for sexually transmitted diseases must be systematically performed in patients presenting with idiopathic voiding disorders.

[Pseudo-tumoral colic metaplasia of the urinary bladder]. / Métaplasie colique pseudo-tumorale de la muqueuse vésicale.

Colic metaplasia of the urinary bladder is a rare disease, secondary to a chronic irritative factor. In its minor form, it has the same clinical features as simple cystitis, but its major pseudoneoplastic form may be mistaken for bladder tumor. The diagnosis is essentially histological. Treatment is based on eradication of the irritative factor and of the resection of pseudoneoplastic form. Surgery is performed in the case of complications of this disease. The clinical course is unclear, requiring long-term surveillance. We report one case of colic-type glandular metaplasia of the urinary bladder in a 50 years-old patient. The clinical symptomatology was dominated by hematuria and pollakuria. A bladder neoplasm was highly suspected in ultrasound and endoscopic findings. The patient underwent a transurethral resection of the bladder tumor. Histological examination of of resection shavings revealed a colic-type glandular metaplasia.

[Bilateral malignant non-Hodgkin's lymphoma]. / Lymphome malin non-Hodgkinien testiculaire bilatéral.

Non Hodgkin's lymphoma (NHL) of the testis in young patient are rare. Bilateral involvement varies from 5 to 20% of cases and has a negative prognosis. The authors report a case of bilateral non Hodgkin's lymphoma of the testis in a 35 year old man. The patient died six months after the diagnosis.

[Penile reconstruction following amputation by electrocution]. / Reconstruction pénienne après amputation par électrocution.

We report a case of penile reconstruction after traumatic loss of the penis in a 27-year old man who was electrocuted. Phalloplasty using the remaining stumps of the corpora cavernosa was performed. The functional and cosmetic aspects of the organ are good.